UIWWSJTY  OF  CALIFORNIA 

COLLEGE  OF  MEDICINE 

LIBRARY 

AUG  2  2  1972 
IRVINE,  CALIFORNIA  92664 


cutruj 


, 

f«.|1;|fl    I 

•  ' 


»» 


THE 


SCIENCE   AND   ART 


OF 


OBSTETRICS. 


BY 
THEOPHILUS   PARYIN,  A.M.,  M.D.,  LL.D., 

PROFESSOR    OF  OBSTETRICS    AND    DISEASES    OF    WOMEN   AND   CHILDREN,  JEFFERSON   MEDICAL  COLLEGE  ; 

EX-PRESIDENT  OF  THE  STATE  MEDICAL  SOCIETY  OF  INDIANA,  OF  THE  AMERICAN  MEDICAL  JOURNALISTS' 

ASSOCIATION,  OF  THE  AMERICAN  MEDICAL  ASSOCIATION,  OF  THE  PHILADELPHIA 

OBSTETRICAL  SOCIETY,  OF  THE  AMERICAN  ACADEMY  OF  MEDICINE, 

AND  OF  THE  AMERICAN  GYNECOLOGICAL  SOCIETY  | 

ONE  OF  THE  HONORARY  PRESIDENTS  OF  THE  OBSTETRIC  SECTION,  BERLIN  INTERNATIONAL  CONGRESS,  1890, 

AND  OF  THE  PERIODIC  INTERNATIONAL  CONGRESS  OF  GYNECOLOGY  AND  OBSTETRICS,  BRUSSELS,  1892  ; 

HONORARY  MEMBER   OF  THE    WASHINGTON  OBSTETRICAL    AND   GYNECOLOGICAL 

SOCIETY,  OF  THE  DISTRICT  OF  COLUMBIA  MEDICAL  SOCIETY,  OF 

THE  STATE  MEDICAL  SOCIETY  OF  VIRGINIA, 

AND  OF  THAT  OF  DELAWARE  ; 

HONORARY  FELLOW  OF  THE  EDINBURGH  OBSTETRICAL  SOCIETY,   AND  OF  THE  BERLIN  SOCIETY  OF 
OBSTETRICIANS  AND    GYNECOLOGISTS,  ETC. 


THIRD  EDITION,  CAREFULLY  REVISED. 


ILLUSTRATED  WITH  269  WOOD-CUTS  AND  TWO  COLORED  PLATES. 


PHILADELPHIA: 
LEA    BROTHERS    &    CO. 

1895. 


\/U6>  (oo 


Entered  according  to  the  Act  of  Congress,  in  the  year  1895,  by 

LEA  BROTHERS  &  CO., 
In  the  Office  of  the  Librarian  of  Congress.     All  rights  reserved. 


PHILADELPHIA  : 
DORNAN,    PRINTER. 


TO 

THE    CLASS    1894-95    JEFFERSON    MEDICAL   COLLEGE. 

YOUNG   GENTLEMEN: 

IN  dedicating  to  you  the  third  edition  of  my  work  upon  Obstetrics  I  testify 
the  strength  and  happiness  your  industry,  fidelity,  and  loyalty  have  given  me. 

Let  me  add  to  this  note  a  quotation  from  one  of  the  ablest  and  most  eminent 
of  my  predecessors,  one  of  the  greatest  of  American  medical  teachers,  the  late 
Dr.  Charles  D.  Meigs,  asking  you  to  make  his  prayer  the  rule  of  your  lives  : 
"  I  pray  you  ever  to  look  upon  the  medical  profession  not  as  a  business,  but  as 
a  great  Morality — not  as  a  trade,  but  as  a  Mission  appointed  by  God  for  the 
benefit  of  the  children  of  men." 


(iii) 


PREFACE. 


IN  preparing  the  third  edition  of  this  work  I  have  made  some 
changes  in  the  order  in  which  the  subjects  are  discussed,  taking  that 
adopted  by  me  in  oral  instruction.  Nearly  one-third  of  the  book  has 
been  rewritten,  additional  illustrations  have  been  introduced,  and  my 
endeavor  has  been  to  make  it  a  faithful  reflex  of  obstetric  science  and 
art  at  the  present  hour. 

"The  judicious  Hooker"  said  of  his  age  that  it  "  was  full  of  tongue, 
and  weak  of  brain."  The  present  age  might  be  described  as  full  ot 
tongue,  so  far  as  the  publication  of  many  volumes  in  the  various 
departments  of  Medicine  is  concerned,  but  by  no  means  weak  of  brain, 
as  is  evidenced  by  the  many  excellent  works  on  obstetrics  of  compara- 
tively recent  issue.  The  favorable  reception  of  the  previous  editions 
of  this  treatise,  both  by  the  profession  in  this  country  and  in  Great 
Britain,  has  been  a  source  of  sincere  gratification,  and  I  trust  this  third 
issue  may  be  found  to  merit  continued  favor.  The  author  is  also 
grateful  for  the  many  honors  he  has  received  from  the  profession — 
honors  that  were  often  unexpected,  never  solicited,  and,  therefore, 
more  highly  appreciated. 

The  Contents  and  Index  have  been  prepared  by  my  assistant,  Dr. 
Charles  H.  Reckefus. 

THEOPHILUS  PARVIN. 

PHILADELPHIA,  JULY  20,  1895. 


CONTENTS. 


PAGE 

INTRODUCTION  17 


PART  I. 

SECTION  I. 
PHYSIOLOGY  OF  PREGNANCY. 

CHAPTER  I. 
ANATOMY  OP  THE  PELVIS        . 21 

CHAPTER  II. 
THE  FEMALE  SEXUAL  ORGANS 46 

CHAPTER  III. 
PUBERTY — OVOLATION — MENSTRUATION 92 

CHAPTER  IV. 

CONCEPTION — EARLY  DEVELOPMENT  OP  THE  IMPREGNATED  OVULE — 

FORMATION  OF  DECIDUOUS  MEMBRANES— FCETAL  APPENDAGES  .    108 

CHAPTER  V. 
THE  EMBRYO  AND  F<ETUS — DEVELOPMENT — ANATOMY  AND  PHYSIOLOGY 

OP  THE  FffiTUS — PLURAL  PREGNANCY 138 

CHAPTER  VI. 
CHANGES  IN  THE  MATERNAL  ORGANISM 166 

CHAPTER  VII. 

SIGNS  AND  DIAGNOSIS  OP  PREGNANCY •   .     184 

CHAPTER  VIII. 

THE  DIAGNOSIS  OF  PLURAL  PREGNANCY — DIFFERENTIAL  DIAGNOSIS  OP 
PREGNANCY — DIAGNOSIS  OF  PREVIOUS  PREGNANCY— OF  PERIOD 
OP  PREGNANCY— DURATION  OF  PREGNANCY— DATE  OP  LABOR- 
PRECOCIOUS  BIRTHS — PROLONGED  PREGNANCY — MISSED  LABOR  202 


viii  CONTENTS. 

CHAPTER  IX. 

THE  MANAGEMENT  OF  PREGNANCY  .... 

SECTION   II. 
PHYSIOLOGY  OF  LABOR. 


CHAPTER  X. 

CAUSES  OF  LABOR— PRECURSORY  SYMPTOMS— PHYSIOLOGICAL  PHE- 
NOMENA—CHANGES OF  THE  FORM  OP  THE  HEAD  IN  VERTEX 
PRESENTATION— CAPUT  SUCCEDANEUM 231 

CHAPTER  XI. 
THE  MECHANICAL  PHENOMENA  OF  LABOR 250 

CHAPTER  XII. 
THE  CONDUCT  OF  LABOR 289 

CHAPTER  XIII. 

THE  CONDUCT  OF  LABOR  (CWm»e<Z)— OCCIPITO-POSTERIOR  POSITIONS — 

FACE,  BROW,  AND  PELVIC  PRESENTATIONS— TWINS       .        .        .    318 

SECTION   III. 
PHYSIOLOGY  OF  THE  PUERPERAL   CONDITION. 

CHAPTER  XIV. 

THE  PHYSIOLOGY  AND  THE  MANAGEMENT  OF  THE  PUERPERAL  STATE  .    333 


PART   II. 

SECTION  I. 

THE  PATHOLOGY  OF  PREGNANCY. 
INTRODUCTORY 359 

CHAPTER  I. 

ECTOPIC  DEVELOPMENT  OF  THE  OVUM  OR  OF  THE  PLACENTA  .    360 


CONTESTS.  ix 

CHAPTER  II. 

PAGE 

DISEASES  THAT  ABE  EXAGGERATIONS  OF  PHYSIOLOGICAL  CONDITIONS 

OF,  OR  OTHERWISE  DEPENDENT  UPON,  PREGNANCY     .        .        .    395 

CHAPTER  III. 
ECLAMPSIA 406 

CHAPTER  IV. 

CHRONIC  AND  ACUTE  DISEASES  IN  PREGNANCY 420 

CHAPTER  V. 

DISEASES  OF  THE  SEXUAL  ORGANS— URINARY  DISORDERS— TRAUMATISM    433 

CHAPTER  VI. 

DISEASES  OF  THE  OVUM — DEATH  OF  THE  F<ETUS — ABORTION — PREMA- 
TURE LABOR 447 

SECTION   II. 

PATHOLOGY  OF  LABOR. 
INTRODUCTORY 477 

CHAPTER  VII. 
ANOMALIES  OF  THE  PELVIS 493 

CHAPTER  VIII. 

ANOMALIES  OF  THE  FCETUS  AND  THE  FCETAL  APPENDAGES   .        .        .522 

CHAPTER  IX. 

INJURIES  OF  THE  MATERNAL  SOFT  PARTS 543 

CHAPTER  X. 

OBSTETRIC  OPERATIONS 573 

CHAPTER  XI. 
THE  FORCEPS 589 

CHAPTER  XII. 

MANUAL  REMOVAL  OF  THE  PLACENTA — SYMPHYSEOTOMY      .        .        .    620 

CHAPTER  XIII. 
C^SAREAN  OPERATION  AND  ITS  SUBSTITUTES 625 

CHAPTER  XIV. 
EMBRYOTOMY  631 


x  CONTENTS. 

SECTION   III. 
THE  PATHOLOGY  OF  THE  PUERPERAL  STATE. 

CHAPTER  XV. 

PAGE 

DISEASES  OF  THE  BREAST — DISEASES  OF  THE  NIPPLE — MASTITIS— MALA- 
RIAL FEVER— SCARLATINA — ERYSIPELAS — PUERPERAL  TETANUS 
— MENTAL  DISORDERS— PARALYSIS  AND  NEURALGIA  OF  THE 
LOWER  LIMBS 641 

CHAPTER  XVI. 
PUERPERAL  FEVER 651 

CHAPTER  XVII. 

SUDDEN  DEATH  IN  LABOR  OR  AFTER  LABOR — DISEASES  OF  THE  NEW- 
BORN 672 


EKRATA. 

Page  17,  foot-note,  "  mede-gemoct "  should  be  ''  inede-genoot." 

Page  44,  "Vernier"  should  be  "  Varnier." 

Page  52,  second  line  from  foot,  "  organ  "  should  be  "  organs." 

Pages  329  and  330,  read  "  Farabeuf "  instead  of  "  Faraboeuf." 

Page  349,  twelfth  line  from  foot,  put  "must"  for  "much." 

Page  361,  ninth  line  from  top,  ".115  "  instead  of  "  108." 

Page  405,  "Borak"  should  be  "Porak." 

Page  449,  "Oregon"  should  be  "Washington." 

Page  657,  omit  "  general "  in  second  line  from  foot. 


THE  SCIENCE  AND  THE  ART 


OBSTETRICS. 


INTKODUCTIOK. 

OBSTETRICS,  the  name  given  to  one  of  the  three  fundamental  divi- 
sions of  medicine,  is  derived  from  the  two  words  ob  and  stare,  "  to 
stand  before,"  and  strictly  defined  means  the  care  of  women  during 
childbirth ;  but  general  use  has  exteuded  the  meaning  of  the  term,  so 
that  it  includes  also  the  care  of  women  in  pregnancy,  and  in  the  puer- 
peral state,  or  puerperality. 

The  words  midwifery,  tocology,  parturition,  and  accouchement  have 
been  and  still  are  more  or  less  used  as  synonyms  for  obstetrics.  The 
first  term  etymologically  means,  and  for  some  centuries  practically 
meant,  attendance  by  women  upon  women  in  labor.  The  name  mid- 
wife,1 variously  spelled,  is  first  met  with  in  the  fourteenth  century, 
while  the  coarse,  contradictory  compounds,  man-midwife  and  man- 
midwifery,  do  not  appear  until  some  two  or  three  hundred  years  later. 
Accouchei — from  ac  and  coucher,  a  derivation  that  brings  to  mind  the 
expression  "  put  to  bed,"  once  not  unfrequently  used  for  attendance 
upon  a  case  of  labor — is  the  origin  of  the  noun  accouchement;  but 
although  the  last  term  has  been  adopted  from  the  French  into  the 
English  language,  it  has  not  by  general  use  acquired  full  right  of  domi- 
cile. Tocology  is  a  word  rarely  used  by  the  profession  ;  and  parturition, 
from  the  Latin  partus,  has  been  by  some  authors  restricted  to  the  phe- 
nomena of  labor  occurring  in  inferior  animals.  It  has  seemed  to  me 
that  maieutics  is  a  better  term,  were  it  generally  adopted,  than  any  of 

i  I  am  indebted  to  Professor  March,  of  Lafayette  College,  Easton,  Penn.,  for  the  following  note  : 
Midwif  does  not  appear  in  the  Anglo-Saxon  so  far  as  yet  explored ;  but  in  the  earliest  Old  Eng- 
lish vocabulary,  the  Promptorium  Parvulorum,  is  mydwife,  obstetrix  (A.  D.  1440).  It  is  found 
earlier,  in  Piers  Plowman,  A.  D.  1394 ;  Myrc's  Duties  of  a  Parish  Priest,  A.  D.  1400,  spelt  mydwi/f 
and  midwif.  In  Wycliffe's  Bible,  A.  D.  1380,  it  is  medewife,  and  in  the  later  version  of  that  Bible 
mydwii/i;  William  de  Shoreham's  Poems,  A.  D.  1330,  medewif.  This  is  the  earliest  appearance  I 
know  of. 

I  suppose  it  to  be  from  mid  and  wif.  The  prefix  mid  is  common.  Mid-coyshta,  &  coworker,  is 
found  in  Anglo-Saxon ;  in  Dutch,  mede-broeder,  a  companion  ;  German,  mit-bruder;  D.  mede-gemoct, 
G.  mit-helfer,  etc.  The  idea  is  that  of  the  Spanish  co-madre,  co-mother,  a  midwife,  and  like  the 
German  bei-frau.  It  may  be  conjectured  that  as  a  doctor's  word  it  was  liable  to  fanciful  learned 
spelling,  and  that  the  Latin  medius  led  to  its  being  spelt  medewif  occasionally,  or  that  the  Dutch 
form  influenced  it.  At  any  rate,  this  bad  spelling  led  to  the  theory  that  it  was  mede-wife,  which 
has  been  favored  by  Trench  and  others.  The  theory  working  in  the  minds  of  the  early  writers 
may  also  have  led  to  the  spelling.  It  is,  however,  a  comparatively  rare  spelling,  and  the  deriva- 
tion suggested  by  it  improbable. 

2 


1 8  INTB  OD  UCTION. 

those  mentioned.  It  is  more  euphonious  than  obstetrics,  and  is  equally 
classic  in  origin — paievo.  and  uaitv-fc  a  male  obstetrician,  and  paiev-f/p  a 
female  obstetrician — and  does  not  prejudice  the  sex  of  the  attendant, 
as  the  word  midwifery  does.  But  the  substitution  of  obstetrics  by 
maieutics  would  be  regarded  as  too  great  an  innovation,  and  hence  the 
former  will  be  used  in  this  treatise. 

Obstetric  science  means  the  classified  knowledge  of  the  laws  of  human 
reproduction ;  obstetric  art  includes  the  rules  drawn  from  those  laws,  or 
from  intelligent  experience,  which  are  to  be  observed  in  individual  cases 
of  women  in  pregnancy,  in  labor,  or  in  childbed.  While  obstetric  art 
may  claim  an  antiquity  as  great  as  either  of  the  other  departments  of 
medicine,  obstetric  science  is  of  recent  origin. 

The  tardy  development  of  obstetric  science,  is  to  be  chiefly  attributed 
to  the  fact  that  childbirth  being  regarded,  justly,  as  a  physiological 
function,  and  pathological  conditions  comparatively  seldom  occurring 
in  its  course,  the  practice  of  the  obstetric  art  was  almost  exclusively  in 
the  hands  of  ignorant  matrons ;  educated  physicians  were,  if  consulted 
at  all,  only  called  in  case  of  serious  difficulty.  In  the  time  of  Hippo- 
crates dividing  the  umbilical  cord  seems  to  have  been  considered  the 
chief  duty  of  the  midwife ;  she  was  called  the  omphalotomist.  There 
could  be  but  little  progress  with  so  narrow  a  conception  of  the  office 
and  with  the  scant  qualifications  of  those  assuming  it.  It  is  true  that 
at  one  time  in  the  history  of  Athens,  if  the  story  concerning  Agnodice 
be  accepted,  men  only  were  permitted  to  practise  obstetrics ;  but  this 
custom  was  altogether  exceptional,  and  even  in  the  most  enlightened 
nations  the  rule,  until  comparatively  recent  years,  was  that  women  in 
labor  were  under  the  care  of  one  of  their  own  sex.  So  universal  was 
the  custom  of  employing  midwives,  and  so  strong  the  prejudice  against 
men  engaging  in  obstetric  practice,  that  in  1522  Dr.  Wertt,  of  Ham- 
burg, who,  having  put  on  the  dress  of  a  woman,  and  thus  disguised 
attended  a  case  of  labor,  was  burned  alive  for  the  offence;  and,  a  little 
more  than  a  century  later,  Dr.  Percivall  Willughby,  an  eminent  English 
physician,  assisted  his  daughter,  who  was  a  midwife,  in  a  case  of  difficult 
labor,  crawling  into  the  darkened  room  of  the  parturient  on  his  hands 
and  knees  without  her  knowledge. 

Chereau  remarks  that  obstetrics  was  at  first  empirical,  then  super- 
stitious, then  scholastic,  that  is  to  say,  the  almost  absolute  slave  of 
theories  and  discussions,  and  that  it  did  not  attain  finally  a  scientific 
character  until  the  sixteenth  and  seventeenth  centuries. 

The  obstetrician  has  a  graver  responsibility  than  has  either  the  medi- 
cal or  surgical  practitioner,  for  he  has  charge  of  two  lives  instead  of 
one ;  while  his  efforts  are  directed  to  saving  both,  yet  in  some  instances 
it  may  be  that  the  one  must  be  sacrificed  for  the  salvation  of  the  other, 
or  saved  at  great  risk  to  the  other  :  hence  may  arise  the  most  serious 
questions  in  casuistry. 

The  importance  of  obstetric  knowledge  is  further  shown  by  the  fact 
that  very  frequently  the  emergencies  which  occur  in  the  practice  of  the 
art  are  sudden,  and  must  be  met  promptly  if  successfully.  They  may 
give  no  time  for  consulting  books  or  a  fellow-practitioner,  but  immediate 
as  is  the  peril  must  be  the  means  to  avert  it. 


INTRODUCTION.  19 

Further,  should  an  unfavorable  result  occur,  the  public  is  apt  to  visit 
unjust  reproach  upon  the  obstetrician ;  it  is  slow  to  understand  how 
that  which  is  usually  a  physiological  process  may  end  in  death  or  in 
lasting  disability.  The  obstetrician  thus  not  only  rests  under  greater 
responsibility  than  the  physician  or  the  surgeon,  but  is  also  liable  to 
severer  censure  in  case  of  failure  or  misfortune. 

This  work  is  divided  into  two  parts,  the  first  relating  chiefly  to 
physiology,  and  the  second  to  pathology.  The  former  includes  the 
physiology  of  pregnancy,  of  labor,  and  of  the  puerperal  state,  and  the 
latter  the  pathology  of  each  of  these.  In  connection  with  the  pathology 
of  labor  obstetric  operations  will  be  presented,  and  in  that  of  the  lying- 
in  there  will  be  embraced  not  only  the  diseases  of  the  mother  but  also 
those  of  the  newborn. 

The  anatomy  of  the  pelvis  and  that  of  the  female  sexual  organs, 
with  their  physiology,  will  precede  and  introduce  the  physiology  of 
pregnancy. 


PART  I. 

SECTION  I. 
THE  PHYSIOLOGY  OF  PREGNANCY, 


CHAPTER    I. 

ANATOMY   OF   THE   PELVIS. 

THE  pelvis  is  that  part  of  the  skeleton  placed  at  the  inferior  por- 
tion of  the  body  which  receives  the  weight  of  the  head  and  trunk  and 
transmits  it  to  the  lower  limbs.  It  has  its  name  from  a  supposed  re- 
semblance in  form  to  a  basin  once  used  by  barbers,  or  from  the  fact 
that  it  serves  as  a  temporary  receptacle  for  certain  secretions.  Within 
or  upon  the  pelvis  the  organs  of  reproduction  are  placed ;  through  its 
canal  the  foetus  and  its  appendages  pass ;  and  the  most  serious  difficul- 
ties in  labor  arise  from  its  deformities.  The  study  of  the  pelvis,  there- 
fore, is  the  first  part  of  obstetrics ;  this  knowledge  is  the  very  alphabet 
of  obstetric  science,  and  is  the  foundation  of  obstetric  art. 

The  anatomical  pelvis  is  formed  by  the  union  of  four  bones,  viz., 
the  two  ossa  innominata,  the  sacrum,  and  the  coccyx ;  the  obstetric 
pelvis  includes  also  the  last  lumbar  vertebra.  But  while  the  static 
pelvis  is  thus  constituted,  the  dynamic  pelvis — the  pelvis  in  the  living 
subject  and  in  labor — has  in  addition  certain  structures  which  make  its 
floor  and  prolong  the  birth-canal ;  it  is  necessary  for  the  obstetrician1 
to  know  two  pelves :  the  one  osseous,  fixed,  passive ;  the  other  soft, 
mobile,  active  The  former  will  be  described  first. 

PELVIC  JOINTS.  Seven  joints  unite  the  bones  forming  the  obstetric 
pelvis.  They  are  three  sacro-lumbar,  two  sacro-iliac,  one  sacro-coccygeal, 
and  one  pubic.  Five  of  these  joints  are  amphiarthroidal. 

SACRO- VERTEBRAL  JOINTS.  The  sacrum  articulates  with  the  last 
lower  lumbar  vertebra  by  the  upper  surface  of  the  body  of  the  first 
sacral  vertebra  and  by  the  two  facets  of  the  articular  apophyses  of  this 
vertebra.  Corresponding  surfaces  are  presented  by  the  under  surface 
of  the  last  lumbar  vertebra ;  the  union  is  similar  to  that  existing 
between  the  other  vertebra.  A  remarkable  peculiarity  of  the  articula- 
tion is  that  the  inter-vertebral  disk  of  fibre-cartilage  is  twice  as  thick 
in  front  as  it  is  behind,  and  thus  the  sacro-vertebral  angle  is  formed.2 
The  pelvic  inclination  does  not  depend  entirely  upon  the  angle,  but  in 
part  upon  the  obliquity  of  the  innominate  bones  to  the  sacrum.  The 

1  Boisaard  :  De  la  forme  de  1' Excavation  Pelvienne.    Paris,  1884. 

2  Morris :  Anatomy  of  the  Joints. 


22  PHYSIOLOGY  OF  PREGNANCY. 

union  between  the  bodies  of  the  vertebrae  is  amphiartbrodial,  but  that 
between  the  apophyses  is  arthrodial. 

SACRO-ILIAC  JOINTS.  According  to  Sappey,  these  joints  are  inter- 
mediate between  mobile  and  semi-mobile  joints,  though  classed  by  most 
authorities  as  amphiarthrodial.  Anatomists  in  general  state  that  the  auric- 
ular surface  of  the  innominate  bone  and  the  corresponding  surface  of  the 
sacrum  are  covered  with  cartilage,  the  covering  being  much  thicker  upon 
the  latter  than  upon  the  former ;  that  which  is  upon  the  innominate  is 
fibro-cartilage ;  that  of  the  sacrum  consists,  first,  of  cartilage  adhering 
to  the  bone ;  and,  second,  of  fibro-cartilage.  The  existence  of  a  synovial 
membrane,  especially  distinct  in  case  of  pregnancy,  is  taught  by  some 
authors.  Gray,  for  example,1  states  that  in  the  early  period  of  life, 
occasionally  in  the  adult,  and  in  the  female  during  pregnancy,  the  inter- 
vening cartilages  are  in  part  smooth  and  lined  by  a  delicate  synovial 
membrane.  Morris,2  however,  holds  that  the  cartilaginous  mass  uniting 
these  bones  is  single,  and  not  composed  of  two  plates  with  a  synovial 
space  between  them,  stating  that  such  may  be  the  case  sometimes,  but 
that  it  is  not  constant,  certainly  not  in  the  male,  though  more  frequent 
in  the  female ;  if  two  plates  are  present,  the  joint  is  arthrodial.3  The 
joint  is  further  secured  by  the  following  six  ligaments  :  the  ilio-lumbar, 
extending  from  the  transverse  process  of  the  last  lumbar  vertebra  to  the 
crest  of  the  ilium,  is  a  firm  band  of  fibrous  tissue  which  not  only  greatly 
strengthens  the  joint,  but  helps  to  form  the  posterior  wall  of  the  false 
pelvis ;  the  antero-superior,  the  antero-iuferior,  the  postero- superior, 
the  postero-iuferior,  and  the  interosseous  ligament  complete  the  direct 
means  by  which  this  joint  is  made  one  of  the  strongest  in  the  body. 
But  additional  strength  is  given  to  it  by  the  sacro-sciatic  ligaments. 
The  great  sacro-sciatic  ligament,  known  also  as  the  tubero-sacral  liga- 
ment, arising  from  the  posterior  part  of  the  superior  curved  line  of  the 
dorsum  of  the  ilium,  from  the  postero-inferior  ilio-sacral  ligament,  from 
the  side  of  the  sacrum  and  of  the  coccyx,  is  attached  to  the  lower  por- 
tion of  the  ischium  and  to  its  ramus  ;  this  ligament  is  broad  at  first  and 
then  in  its  middle  is  narrowed,  but  again  widens  as  it  approaches  its 
points  of  attachment.  The  less  sacro-sciatic  ligament,  or  sacro-spinous 
ligament,  is  in  front  of  the  former,  and  is  triangular  in  shape ;  it  arises 
from  the  sides  of  the  sacrum  and  the  coccyx,  and  is  at  first  confounded 
with  the  great  ligament ;  afterward  it  becomes  distinct  from  the  former 
in  making  the  lower  boundary  of  the  great  sciatic  foramen,  and  passes 
to  its  attachment  to  the  spinous  process  of  the  ischium. 

When  in  labor  the  head  has  descended  into  the  pelvic  cavity,  the 
expulsive  force  drives  it  against  the  lower  portion  of  the  sacrum,  and 
hence  results  a  strain  upon  the  sacro-iliac  joints  tending  to  throw  the 
lower  part  of  the  sacrum  backward ;  but  nature  guards  against  such 
dislocation  by  these  strong  fibrous  bands  which  unite  the  sacrum  and 
the  ischium. 

THE  SACRO-COCCYGEAL  JOINT.  This  is  composed  of  two  articular 
surfaces,  an  interosseous  fibro-cartilage,  and  four  peripheral  ligaments. 
The  retrocession  of  the  coccyx  thus  secured  adds  materially  to  the 

i  Anatomy.  2  Anatomy  of  the  Joints. 

8  J.  Veil,  in  MUller's  Ilandbuch  der  Geburtshtilfe,  asserts  the  presence  of  a  true  synovial  joint 
cavity. 


ANATOMY  OF  THE  PELVIS.  23 

antero-posterior  diameter  of  the  outlet.  Sappey  states  that,  prior  to 
their  consolidation,  all  the  inter-coccygeal  articulations  are  symphyses, 
and  Lenoir  that  the  backward  movement  referred  to  takes  place  between 
the  first  two  bones  of  the  coccyx,  as  between  the  first  and  the  sacrum ; 
exceptionally  this  motion  is  found  to  be  between  the  second  and  the 
third,  or  between  the  third  and  fourth.  Verneau1  says  that  he  has  fre- 
quently found  even  in  young  subjects  complete  synostosis  of  the  sacrum 
and  the  coccyx,  and  describes  the  two  as  a  single  bone. 

THE  PUBIC  JOINT.  Fibro-cartilage  similar  to  that  of  the  interver- 
tebral  disks  is  firmly  fastened  to  the  articulating  surface  of  each  pubic 
bone.  The  fibro-cartilage  is  soft  in  the  middle,  firm  externally ;  it  is 
much  thicker  in  front  than  it  is  behind — thicker,  too,  in  females  than  it 
is  in  males ;  the  presence  of  a  synovial  membrane  is  asserted  by  some, 
Allen,  for  example,2  stating  that  in  the  adult  male  its  size  is  not  greater 
than  that  of  a  split  pea,  but  that  it  is  larger  in  the  adult  female,  and  in 
the  parturient  may  involve  the  entire  thickness  of  the  joint.  Morris, 
however,  only  describes  a  fissure  running  through  more  or  less  of  the 
antero-posterior  as  well  as  the  vertical  depth  of  the  cartilage ;  it  partially 
divides  the  cartilage  into  two  plates,  with  a  minute  viscid  pulp  or  a  little 
fluid  in  the  interspace ;  it  is  found  in  males  as  well  as  in  females,  but 
not  constantly  in  either  sex.  Depaul  and  other  French  authorities 
generally  deny  the  presence  of  a  synovial  membrane  in  the  pubic  joint; 
this,  too,  is  the  teaching  of  most  anatomists.  Four  ligaments  add  to  the 
strength  of  the  joint.  These  are  the  posterior,  which  is  chiefly  thickened 
periosteum ;  the  anterior,  thicker  and  stronger  than  the  preceding,  is 
formed  by  several  layers  of  fibres  crossing  each  other  obliquely,  some  of 
them  continued  into  the  inferior  ligament;  the  superior  consists  of  layers 
of  yellowish  fibres  attached  to  the  pubic  crest  on  either  side,  and  at  the 
middle  closely  united  with  the  interosseous  cartilage ;  and,  finally,  the 
inferior  or  subpubic  ligament.  The  last,  also  called  ligameutum  arena- 
turn,  three-eighths  of  an  inch  in  its  vertical  measurement,  is  composed  of 
closely  joined  fibres,  and  fills  up  the  angle  made  by  the  pubic  rami, 
forming  an  arch,  the  pubic  arch,  a  part  of  as  great  obstetric  importance 
in  the  outlet  as  the  sacro-vertebral  angle  is  in  the  inlet  of  the  pelvis. 

MOVEMENTS  OF  THE  PELVIC  JOINTS.  Of  course,  there  are  in  the 
three  sacro-vertebral  articulations  movements  similar  to  those  of  the 
vertebral  joints  elsewhere.  There  is  also,  as  has  been  before  mentioned, 
an  important  movement  in  the  sacro  coccygeal  joint,  or  in  one  or  more 
intercoccygeal  joints,  allowing  retropulsion  or  pushing  back  of  the 
coccyx,  thus  increasing  the  antero-posterior  diameter  of  the  pelvic  out- 
let. But  are  there  movements  in  the  other  pelvic  joints  by  which  pelvic 
diameters  are  notably  increased  ?  Dr.  J.  Matthews  Duncan  holds  that 
in  labor  important  movements  occur  in  the  sacro-iliac  joints,  movements 
which  he  describes  as  an  elevation  and  a  depression  of  the  pubic  joint; 
or,  if  the  sacrum  be  regarded  as  the  moving  bone,  it  has  a  nutatory 
motion  upon  an  imaginary  transverse  line  passing  through  its  second 
vertebra.  Elevation  of  the  pubic  joint,  or  its  equivalent  forward  move- 
ment of  the  superior  part  of  the  sacrum,  lessens  the  antero-posterior 

1  Le  Bassin  dans  les  Sexes  et  dans  les  Races.  -  Human  Anatomy. 


24  PHYSIOLOGY  OF  PREGNANCY. 

diameter  of  the  inlet,  but  increases  the  corresponding  diameter  of  the 
outlet.  On  the  other  hand,  Mattei  and  Laborie  assert  an  increase  in  the 
transverse  diameter  of  the  outlet  by  the  wedge-like  pressure  of  the  foetal 
head.1  But  the  form  of  the  articular  surfaces  of  the  sacrum  and  the 
innominate  bones  is  such — elevations  upon  the  one  fitting  into  depres- 
sions on  the  other,  and  the  reverse — that  any  movement  between  these 
bones,  whether  it  be  described  as  rotation  of  the  innominates  upon  the 
sacrum,  or  a  movement  of  the  base  of  the  sacrum  forward,  while  the 
lower  portion  of  the  bone  moves  backward,  seems  improbable,  or  impos- 
sible, in  ordinary  conditions.  Moreover,  the  fixed  position  of  the  sacrum 
is  further  secured  by  its  shape  and  by  the  ligaments  belonging  to  the 
sacro-iliac  joint,  and  also  by  the  sacro-sciatic  ligaments  and  by  the  ilio- 
lumbar  ligaments.  "The  shape  of  the  sacrum  and  the  mode  in  which 
it  articulates  with  the  ossa  innominata  render  its  position  a  secure  and 
ordinarily  an  immovable  one."2  Nevertheless  the  swollen  condition  of 
these  points,  often  so  great  in  the  last  months  of  pregnancy,  may  permit 
in  labor  some  separation,  and  thus  the  area  of  horizontal  pelvic  planes 
be  slightly  increased. 

USES  OF  THE  PELVIC  JOINTS.  If  movements  in  the  pelvic  articula- 
tions are  not  great,  why  is  not  this  osseous  girdle  made  of  a  single  bone  ? 
The  answer  given  by  Depaul  is  that  these  joints  have  as  their  result  the 
decomposition  of  forces,  and  thus  prevent  shocks  and  jars  received  by 
the  lower  limbs  being  transmitted  directly  to  the  vertebral  column.  Thus 
the  uterus  and  the  ovum  as  well  as  the  prolongation  of  the  spinal  cord 
in  the  sacral  canal  are  guarded  from  injury.  These  joints,  especially 
the  pubic,3  are  swelled  during  pregnancy,  permitting  a  slight  separation  ; 
but  such  swelling  may  not  be  chiefly  for  the  increase  of  pelvic  diameters, 
but  a  protection  against  injuries  from  falls  or  jars :  they  serve  a  pur- 
pose similar  to  that  of  the  cushioned  buffers  of  railway  cars. 

THE  PELVIS  AS  A  WHOLE.  Its  external  surface.  This  is  of  no  great 
obstetric  importance ;  still  a  few  points  are  worthy  of  attention.  One 
feature  of  the  pelvis  is  most  striking — the  great  difference  as  to  complete- 
ness between  its  anterior  and  its  posterior  portion.  Behind,  the  bony 
wall  is  complete  from  the  beginning  of  the  last  lumbar  vertebra  to  the 
tip  of  the  coccyx ;  while  in  front  the  girdle  presents  a  wide  gap  from 
the  anterior  margin  of  the  iliac  bones,  above  the  pubic  joint;  the  girdle 
is  completed  at  the  joint,  but  below  another  gap  is  formed,  its  bound- 
aries being  the  divergent  ischio- pubic  rami.  The  ischio-pubic  foramen4 
is  observed  on  either  side ;  this  foramen  is  closed  by  a  membrane,  and 

1  Dr.  Driver,  in  a  paper  read  before  the  Massachusetts  Medical  Society,  June,  1887,  from  a  study 
of  nearly  300  cases  in  his  practice,  concluded  that  in  a  large  percentage  of  women  there  was  an 
increase  of  about  one-third  of  an  inch  in  the  pelvic  diameters  from  relaxation  of  the  pelvic  liga- 
ments. 

2  Morris. 

3  Budin  (Progr&s  Medical,  1875)  examined  more  than  eighty  pregnant  women  to  ascertain  whether 
there  were  movements  in  the  pubic  joint.    The  method  of  examination  was  to  introduce  the  index- 
finger  into  the  vagina  and  apply  the  pulp  of  the  finger  directly  against  the  Inferior  margin  of  the  joint 
while  the  subject  was  standing,  and  then  have  her  walk.    At  each  step  she  took  he  found  that  the 
finger  was  pushed  down  by  the  descending  pubic  bone  of  one  or  of  the  other  side ;  that  bone 
descended  which  corresponded  with  the  limb  moved ;  the  one  corresponding  with  the  limb  that 
was  fixed  remained  without  change  in  position.    His  conclusions  were,  that  in  all  pregnant  women 
there  was  in  the  last  months  of  pregnancy  a  certain  mobility  in  the  pubic  joint ;  this  mobility  is 
greater  as  the  pregnancy  approaches  its  end;  almost  absent  in  primiparse,  it  increases  with  the 
number  of  pregnancies.    Even  where  there  was  very  considerable  mobility  the  subjects  walked 
without  difficulty. 

4  Verneau  remarks,  op.  cit.,  that  "  foramen  ovale  "  is  incorrect,  and  "  obturator"  meaningless. 


ANATOMY  OF  THE  PELVIS.  25 

covering  the  membrane  a  muscle,  known  as  the  obturator  exteruus. 
The  posterior  surface,  formed  chiefly  by  the  sacrum  and  coccyx,  is  tri- 
angular, the  base  of  the  triangle  being  superior.  In  the  median  line 
the  sacral  crest,  formed  by  the  fusion  of  the  spinous  processes  of  the 
sacral  vertebrae,  is  found ;  on  either  side  of  the  iliac  tuberosity,  and 
intervening  between  these  and  the  sacral  crest,  is  a  gutter,  the  two  por- 
tions being  occupied  in  the  fresh  subject  by  the  sacro-lumbar  muscles, 
while  at  the  external  side  of  each  the  posterior  sacral  foramina  open. 
In  general  the  rough,  irregular  surface  of  the  pelvis  posteriorly  is  in 
striking  contrast  with  the  corresponding  internal  surface. 

Internal  surface  of  the  pelvis.  Though  the  external  surface  of  the 
pelvis  is  rough  and  irregular,  and  presents  no  lines  for  artificial  divi- 
sion, the  internal  surface  is  smooth  and  symmetrical  and  is  plainly  divisi- 
ble into  two  parts,  an  upper  and  a  lower,  the  dividing-line  being  formed 
by  the  upper  anterior  margin  of  the  sacrum  and  its  alse,  and  the  innom- 
inate, or  ilio-pectineal  line  ;  this  is  better  and  more  briefly  called  the 
linea  terminalis.  The  upper  portion  is  known  as  the  false,  superior, 
or  large  pelvis ;  while  the  lower  is  the  true,  inferior,  or  small  pelvis,  or 
simply  the  pelvic  cavity.  The  posterior  wall  of  the  upper,  or  false, 
pelvis  is  formed  by  the  last  lumbar  vertebra  and  the  ilio-lumbar  liga- 
ments ;  its  lateral  walls  are  the  iliac  bones ;  in  front  the  wall  is  absent, 
but  in  the  living  subject  the  gap  is  closed  by  the  lower  portion  of  the 
elastic  abdominal  wall,  which,  readily  yielding,  furnishes  space  for  the 
uterus  enlarging  in  pregnancy. 

The  convergence  of  the  bony  walls  of  the  false  pelvis — a  convergence 
which,  if  continued,  would  cause  them  to  meet  at  a  point  corresponding 
with  the  fourth  sacral  vertebra — has  suggested  the  comparison  of  this 
part  to  a  funnel  which  serves  to  direct  the  foetus  into  the  pelvic  cavity. 
The  comparison  is  more  striking  when  we  remember  that  in  the  living 
subject  the  interval  between  the  anterior  margins  of  the  iliac  bones  is 
closed  by  the  lower  part  of  the  abdominal  wall. 

Measuring  from  the  highest  point  of  the  iliac  crests  to  the  plane  of 
the  inlet,  the  distance  is  a  little  more  than  three  inches  and  a  half,  or 
nine  centimetres  and  a  half.  The  distance  between  the  anterior-superior 
spines  is  about  ten  inches,  or  twenty-six  centimetres,  and  between  the 
anterior-inferior  spines  a  little  more  than  nine  inches,  or  twenty-four 
centimetres  ;  the  widest  interval  between  the  iliac  crests  is  eleven  inches, 
or  twenty-eight  centimetres.  These  measurements  vary  somewhat  in 
different  subjects,  but  any  notable  deviations  from  those  given  of  the 
distances  between  the  iliac  crests,  and  between  the  spinous  processes, 
would  be  indicative  of  pelvic  deformity. 

THE  PELVIC  INLET.  The  entrance  to  the  pelvic  cavity  is  called  the 
inlet,  superior  strait,  brim,  margin,  or  isthmus.  The  fitness  of  the 
term  inlet  is  plain,  whilst,  it  being  "  narrower  than  the  upper  pelvis, 
less  in  extent  than  the  lower,"  there  is  a  fitness  also  in  the  names  strait 
and  isthmus.  Pelvic  deformities  most  frequently  affect  the  inlet,  and 
therefore  its  study  has  special  importance.  Its  form  is  irregular,  and 
has  been  compared  to  an  ellipse,  to  a  circle,  to  a  spherical  triangle,  to 
the  heart  of  a  playing-card ;  it  has  also  been  described  as  oval  and 
as  kidney-shaped.  Its  regularity  of  form  is  chiefly  broken  by  the  pro- 


26  PHYSIOLOGY  OF  PREGNANCY. 

jection  of  the  sacro-vertebral  angle,  commonly  called  the  promontory, 
and  thus  a  large,  round  notch  is  made,  which  is  similar  to  the  notch  in 
the  playing-card  heart. 

The  subjoined  diagram  represents  the  form  of  the  inlet,  and  also  the 
four  diameters  which  are  of  obstetric  importance.  These  diameters  are 
one  antero-posterior,  one  transverse,  and  two  oblique.  The  oblique 
diameters  connect  what  have  been  known  as  the  four  cardinal  points 
of  Capuron,  viz.,  the  right  sacro-iliac  symphysis  with  the  left  ilio- 
pectineal  eminence,  the  left  sacro-iliac  symphysis  with  the  right  ilio- 
pectineal  eminence.  The  first  is  known  as  the  right,1  the  other  as  the 
left  oblique  diameter,  the  sacro-iliac  symphysis  determining  the  name. 


A 

THE  INLET,  OR  SUPERIOR  STRAIT. 

A  P.  Antero-posterior  diameter.  4.3  to  4.5  inches,  or  11-11%  centimetres. 

TS   Transverse.  5.3  "        or      13%  " 

R  0.  Right  oblique.  4.7  to  4.9      "        or  12-12% 

L  0.  Left  oblique.  "        "  "     "  " 

The  circumference  of  the  inlet  is  15-8  inches,  or  40  centimetres. 

Further,  it  will  be  observed  that  the  transverse  diameter,  which  repre- 
sents the  widest  measurement  of  the  inlet,  passes  in  front  of  the  inter- 
section of  the  oblique  diameters,  and  this  is  characteristic2  of  the  normal 
female  pelvis,  indeed  one  of  the  means  by  which  the  female  can  be  dis- 
tinguished from  the  male  pelvis.  The  antero-posterior,  sacro-pubic,  or 
conjugate  diameter  extends  from  the  sacro-vertebral  angle  to  the  pubic 
symphysis.  The  last  is  the  shortest  of  the  four,  while  the  transverse 
is  the  longest ;  but  the  latter,  as  will  be  seen  hereafter,  is  lessened  by 
the  encroachment  of  soft  parts,  so  that  each  oblique  diameter  exceeds  it, 
and  hence  the  frequency  of  oblique  positions  of  the  foetal  head  as  it  enters 
the  inlet. 

In  addition  to  the  autero-posterior  diameter  of  the  inlet  which  has 
been  given,  and  which  may  be  distinguished  as  the  sacro-suprapubic, 
two  other  antero-posterior  diameters  are  to  be  mentioned,  called  the 
sacro-subpubic  and  the  minimum,  useful,  or  true  conjugate;  the  three 
diameters  are  represented  in  Fig.  2,  from  Pinard.  It  will  be  observed 
that  all  these  diameters  start  from  a  common  point  at  the  sacro-vertebral 

1  Some  confusion  is  caused  by  the  fact  that  obstetric  authors  differ  in  the  application  of  the 
terms  right  and  left  to  these  diameters,  one  designating  that  as  right  which  another  calls  left,  and 
vice  versa.    While  the  selection  is  chiefly  arbitrary,  it  seems  more  natural  that  the  relation  of  right 
and  left  be  determined  by  the  sacro-iliac  joint  concerned. 

2  This  statement,  made  by  Verneau,  I  have  verified  in  the  measurements  of  some  twenty  male 
and  female  pelves. 


ANATOMY  OF  THE  PELVIS. 


27 


angle,  but  extend  respectively  to  the  superior  margin  of  the  pubic  joint, 
to  its  inferior  margin,  and  to  its  nearest  point.  In  case  of  pelvic  de- 
formity involving  the  inlet,  it  is  important  to  know  what  the  minimum, 
useful,  or  true  conjugate  diameter  is,  and  this  is  obtained  by  first  ascer- 
taining the  sacro-subpubic  diameter  and  deducting  from  it,  if  the  pubic 
symphysis  measures  one  inch  and  a  half,  four  centimetres,  or  more, 
one-half  to  seven-tenths  of  an  inch  ;  but  if  the  pubic  symphysis  is  less 
than  an  inch  and  a  half,  the  reduction  must  be  one-half  to  three-tenths 
of  an  inch. 

FIG.  2. 


ANTERO-POSTERIOR  DIAMETERS  OF  INLET. 
S  P.  Sacro-suprapubic  diameter. 
S  P".  Sacro-subpubic  diameter. 
S  P".  Minimum  diameter. 


THE  OUTLET  AS  SEEN  FROM  BELOW. 
C.  Under  surface  of  the  coccyx. 
A  P.  The  antero  posterior,  or  coccy- 
pubic  diameter.  T  E.  Transverse 
diameter.  R  0  and  L  0.  Right 
and  left  oblique  diameters. 


THE  PELVIC  OUTLET.  While  the  boundaries  of  the  inlet  are  formed 
of  bone  and  present  a  comparatively  regular  outline,  those  of  the  outle 
are  in  part  ligamentous  and  are  marked  by  projections  of  bone,  the 
ischial  tuberosities  and  the  coccyx,  and  deep  intervals,  the  most  impor- 
tant of  which  is  the  pubic  arch.  Nevertheless,  a  somewhat  rhomboidal 
form  is  attributed  to  the  outlet.  The  subpubic  ligament  is  its  anterior 
boundary,  its  posterior  the  coccyx,  while  intervening  on  either  side  are 
the  ischio-pubic  ramus,  the  ischial  tuberosity,  and  the  lower  surface  of 
the  sacro-sciatic  ligaments.  The  pubic  arch  is  triangular,  the  base  ex- 
tending from  one  to  the  other  ischial  tuberosity,  and  its  apex  rounded 
by  the  subpubic  ligament. 

As  in  the  inlet,  so  in  the  outlet,  four  diameters  are  given,  one  antero- 
posterior,  or  coccy-pubic,  one  transverse,  and  two  oblique.  The  first 
measures  the  distance  from  the  tip  of  the  coccyx  to  the  subpubic  liga- 
ment ;  the  transverse  that  between  the  ischial  tuberosities ;  while  the 
oblique  extend  on  either  side  from  the  middle  of  the  under  surface  of 
the  sciatic  ligaments  to  the  junction  of  the  ischio-pubic  rami.  The 
oblique  diameters  may  be  slightly  increased  by  yielding  of  the  sciatic 
ligaments,  but  this  is  unimportant.  On  the  other  hand,  an  important 
increase  in  the  antero-posterior  results  from  recession  of  the  coccyx,  so 
that  it  becomes  the  longest  diameter  of  the  outlet,  whereas  it  is  the 
shortest  of  the  inlet;  the  latter,  since  it  is  the  shortest  diameter  of  an 


28  PHYSIOLOGY  OF  PREGNANCY. 

ellipse,  is  correctly  called  the  conjugate  ;  but  to  apply  this  term  to  the 
former  is  plainly  an  error,  or  at  least  such  application  is  purely  arbi- 
trary. 

Each  of  these  diameters  is  about  4.3  inches,  or  11  centimetres.  The 
autero-posterior  is  increased  by  the  recession  of  the  coccyx  from  one- 
half  to  one  inch  ;  the  average  increase  is  probably  about  three-fourths  of 
an  inch.  The  circumference  of  the  outlet  is  13.4  inches,  or  34  centi- 
metres.1 

THE  PELVIC  CAVITY.  The  pelvic  cavity,  the  small  or  true  pelvis, 
thus  bounded  by  inlet  and  outlet,  is  somewhat  cylindrical  or  barrel- 
shaped.  Its  walls  measure  one  inch  and  a  half  in  front,  three  inches 
and  a  half  at  the  sides,  and  posteriorly  four  inches  and  a  quarter,  or, 
following  the  curve  of  the  sacrum,  about  five  inches  and  a  half;  the 
corresponding  metric  measurements  are :  3.8,  8.9,  10.8,  and  13.8  centi- 
metres. Mr.  Morris2  calls  attention  to  an  important  fact  in  obstetrics, 
viz.,  that  in  no  horizontal  pelvic  plane  is  the  bony  wall  of  the  pelvis 
complete,  for  opposite  the  pubic  symphysis  is  the  movable  coccyx,  and 
thus  at  one  point  or  at  another  of  the  cylinder  there  is  always  in  some 
part  of  the  plane  either  a  joint  motion  or  that  permitted  by  elastic  tissue. 
The  protection  from  injurious  pressure  thus  secured  to  the  foetus  and 
the  maternal  soft  parts  is  obvious. 

WIDEST  AND  NARROWEST  PART  OF  PELVIC  CAVITY.  The  trans- 
verse measurements  of  the  pelvic  cavity  lessen  from  above  below,  while 
the  antero-posterior  increase.  The  average  diameters  of  the  pelvic 
cavity  are  about  four  and  three-quarters  inches,  or  twelve  centimetres. 
The  antero-posterior  diameter  is  measured  from  the  middle  of  the  pos- 
terior surface  of  the  pubic  joint  to  the  middle  of  the  line  uniting  the 
second  and  third  sacral  vertebrae ;  the  transverse  intersects  and  is  per- 
pendicular to  the  former ;  the  ends  of  the  diameter  are  in  the  vicinity  of 
the  acetabula ;  the  oblique  diameters  connect  the  middle  of  each  great 
sciatic  foramen  with  the  middle  of  the  ischio-pubic  foramen  of  the 
opposite  side.  The  points  which  the  oblique  diameters  connect  not 
being  fixed,  little  importance  is  attached  to  the  latter.  It  is  plain  that 
any  oblong  body — and  the  foetal  head  is  such  a  body — which  has  greater 
length  than  four  and  three-quarters  inches  cannot,  having  entered  the 
pelvic  cavity,  pass  out  of  it  unless  that  part  first  entering  goes  out  first. 

The  narrowest  part  of  the  pelvis  has  for  its  transverse  diameter  the 
distance  between  the  ischial  spines,  and  for  its  antero-posterior  that 
from  the  point  of  the  sacrum  to  the  lower  border  of  the  internal  surface 
of  the  pubic  symphysis;  the  former  is  10.5  centimetres,  or  4.14  inches, 
and  the  latter  11.5  centimetres,  or  4.54  inches.  The  transverse  diameter 
of  the  outlet,  as  before  stated,  is  the  distance  between  the  ischial  tuber- 
osities — 11  centimetres,  or  4.34  inches. 

INCLINED  PLANES  OF  THE  PELVIS.  The  walls  of  the  pelvic  cavity, 
though  presenting  no  natural  lines  of  separation,  have  been  arbitrarily 
divided  so  as  to  represent  certain  inclined  planes  which  were  held  to 
have  an  important  influence  in  .determining  a  part  of  the  mechanism  of 

1  I  have  retained  the  above,  with  illustration,  as  given  in  the  previous  editions,  though  it  will 
be  obvious,  when  considering  the  narrowest  part  of  the  pelvis,  that  the  head  of  the  child  after 
passing  through  that  contracted  portion  will  find  no  resistance  from  the  mobile  coccyx. 

2  Op.  cit. 


ANATOMY  OF  THE  PELVIS. 


labor.  These  divisions  have  varied  with  different  obstetric  teachers. 
The  late  Dr.  Hodge,  for  example,  after  the  antero-posterior  division  of 
the  pelvic  cavity  in  the  median  line,  had  each  half  divided  by  a  line 
beginning  three-quarters  of  an  inch  in  front  of  the  sacro-iliac  joint  and 
extending  downward  to  the  extremity  of  the  spine  of  the  ischium  ;  thus 
two  anterior  and  two  posterior  inclined  planes  were  formed,  and  an 
object  impinging  upon  either  of  the  former  rotated  into  the  pubic  arch, 
while  if  impinging  upon  either  of  the  latter  it  rotated  into  the  hollow 
of  the  sacrum.  Other  authors  make  the  line  of  division  between  an- 
terior and  posterior  plaues  further  forward.  Still  others,  after  dividing 
the  pelvic  walls  into  anterior,  posterior,  and  two  lateral  walls,  divide 
each  of  the  latter — a  lateral  wall  includes  the  part  of  the  pelvis  between 
the  sacro-coccygeal  surface  and  a  line  drawn  from  the  ilio-pectineal  emi- 
nence downward  through  the  ischial  tuberosity — into  two  inclined 
planes,  the  anterior  and  the  posterior.  Figs.  4  and  5  show  the  anterior 
wall  of  the  pelvic  cavity  and  the  lateral  inclined  planes. 


FIG.  4. 


FIG.  5. 


ANTERIOR  PELVIC  WALL  AND  LATERAL  PLANES. 

It  ought,  however,  to  be  said  that  few  obstetric  authorities  now  attach 
to  these  arbitrarily  formed  planes  the  importance  in  explaining  the 
mechanism  of  labor  which  was  once  given  them. 

OBLIQUITY,  HORIZONTAL,  PLANES,  AND  AXES  OF  THE  PELVIS. 
The  pelvis  is  not  in  the  axis  of  the  body,  a  fact  which  is  at  once  evi- 
dent when  one  observes  that  the  sacro-vertebral  angle  is  nearly  four 
inches  higher  than  the  superior  margin  of  the  pubic  joint,  but  it  is 
placed  obliquely  with  regard  to  that  axis,  and  hence  the  expression 
inclination  or  obliquity  of  the  pelvis.  This  obliquity  is  caused,  first,  by 
the  form  of  the  articulating  face  of  the  upper  sacral  vertebra,  which  is 
so  oblique  as  to  make  an  acute  angle  with  the  anterior  surface  of  the 
body  of  the  bone ;  second,  by  the  shape  of  the  cartilage  between  the 
sacrum  and  the  lumbar  vertebra  with  which  it  articulates ;  and  finally 
by  the  obliquity  of  the  innominate  bones  in  their  articulation  with  the 
sacrum.  The  result  of  this  obliquity  is  that  the  weight  of  the  gravid 
uterus  is  borne  chiefly  by  the  anterior  abdominal  wall  and  the  superior 
border  of  the  pubis.  In  order  the  better  to  show  this  obliquity  of  the 


30  PHYSIOLOGY  OF  PREGNANCY. 

pelvis  it  may  be  stated  that  the  angle  made  by  the  antero-posterior 
diameter  of  the  inlet  and  a  line  representing  the  axis  of  the  body  is 
from  130°  to  140°,  and  that  this  diameter  prolonged  in  front  makes 
with  a  horizontal  line  an  angle  of  60°. 

While,  as  taught  by  Naegele,  the  obliquity  of  the  pelvis  was  repre- 
sented by  the  angle  made  by  the  antero-posterior  diameter  of  the  inlet 
with  a  horizontal  line — the  subject  standing — an  angle  which  varied 
from  55°  to  60°,  it  is  now  held  that  this  angle  may  vary  greatly  within 
even  the  lower  of  these  limits,  as  the  following  passage  from  Kleiu- 
wachter1  explains: 

Naegele  understood  by  it  that  angle  which  the  conjugata  vera  makes  with  the 
horizon.  (Fig.  6.) 

Later  researches  showed,  however,  that,  although  this  hypothesis  is  in  general 
true,  still  the  angle  has  no  fixed  size,  but  changes  with  various  positions  of  the 
body.  The  most  reliable  angle  (Fig.  7,  B),  indicating  the  pelvic  obliquity,  is, 
according  to  H.  Mayer,  that  which  a  horizontal  line  makes  with  the  so-called 
diagonal  conjugate,  the  distance  from  the  upper  margin  of  the  pubic  joint  to  the 
middle  of  the  anterior  surface  of  the  third  sacral  vertebra  :  this  angle  measures 
30°.  The  pelvic  inclination,  too  much  overrated  in  former  times  by  Stein  the 
elder  a'nd  Naegele  the  elder,  does  not  have  any  practical  significance,  for  it  may 
be  changed  by  a  corresponding  change  in  the  position  of  the  parturient. 


FIG.  6.  FIG.  7. 


PELVIC  OBLIQUITV.  DIAGONAL  CONJUGATE. 

It  will  be  seen  (Fig.  8)  that  the  coccy-pubic  diameter  prolonged  in 
front  makes  an  angle  with  the  horizontal  line  of  11°,  or  10°  to  11°. 
But  if  the  coccyx  be  pressed  backward,  as  it  is  in  labor,  that  diameter 
coincides  with  the  horizontal  line  at  first,  and  then  forms  an  angle  with, 
but  below  it. 

The  plane  of  the  inlet  is  a  surface  supposed  to  touch  all  points  of 
the  circumference  of  the  inlet ;  the  antero-posterior  diameter  of  the 
inlet  is  a  line  which  measures  that  surface  from  before  backward.  The 
axis  of  the  inlet  is  a  perpendicular  to  the  surface  at  its  middle  point, 
or,  more  simply,  a  perpendicular  to  the  antero-posterior  diameter  at  its 
middle. 

Similarly  the  plane  of  the  outlet  is  a  surface  which  theoretically 
touches  all  points  in  its  circumference ;  the  axis  of  the  outlet  is  a 
perpendicular  erected  at  the  middle  of  its  autero-posterior  diameter. 
As  will  be  seen  from  Fig.  8,  the  axis  of  the  inlet  prolonged  below 

1  Grundriss  der  GeburtshUlfe. 


ANATOMY  OF  THE  PELVIS. 


31 


meets  the  axis  of  the  outlet,  forming  with  it  a  very  obtuse  angle.  In 
the  illustration  this  angle  measures  124°.  Further,  as  shown  in  the 
diagram,  the  two  antero-posterior  diameters  mentioned,  if  prolonged  in 
front  of  the  pubic  joint,  soon  meet ;  but  as  these  lines  simply  represent 
the  middle  of  the  surface  of  the  inlet  and  that  of  the  outlet,  it  follows 
that  the  planes  of  the  inlet  and  outlet  would  in  like  manner  meet,  If 
the  axis  of  the  inlet  be  continued  beyond  the  point  where  it  meets  that 
of  the  outlet,  it  would  strike  the  coccyx — according  to  some,  the  sacro- 
coccygeal  articulation  ;  extended  above,  it  passes  out  at  or  a  little  below 
the  umbilicus.  It  is,  therefore,  obvious  that  the  plane  of  the  inlet  is 
very  oblique,  while  that  of  the  outlet — the  subject  supposed  to  be 
standing — is  nearly  horizontal.  Behind,  the  planes  are  separated  by 
the  length  of  the  anterior  surface  of  the  sacrum  and  coccyx,  while  in 
front  only  the  length  of  the  pubic  joint  intervenes.  It  follows  that  the 


H 

PLANES  AND  AXES  OF  THE  INLET  AND  THE  OUTLET. 

H  0.  Horizontal  line.     V  0.  Vertical  line.    N.  Umbilicus.    A  B.  Axis  of  the  outlet  intersecting, 
at  /,  the  axis  of  the  inlet.    A  P.  Sacro-pubic  diameter.    6?  K.  Coccy-pubic  diameter. 

planes  of  the  pelvic  cavity  cannot  be  parallel,  but  must  converge  as 
they  move  from  the  posterior  wall,  meeting  in  front  of  the  pubic  joint, 
and  are  included  between  the  plane  of  the  inlet  and  that  of  the  outlet. 
To  ascertain  the  mathematical  axis  of  the  pelvic  cavity,  a  series  of 
planes  may  be  imagined  to  extend  from  the  intersection  of  the  inlet  and 
outlet  planes  to  the  anterior  surface  of  the  sacrum  and  coccyx.  Next 
find  the  central  point  of  each  of  these  planes  in  the  pelvic  cavity,  and 
then  a  line  connecting  these  points  is  drawn ;  this  line,  which  is 
curved,  its  concavity  anterior,  represents  the  axis  of  the  pelvis. 

The  pelvic  axis  is  also  called  the  central  line  and  the  line  of 
direction.  It  may  be  defined  as  a  curved  line  passing  through  the 
centre  of  the  pelvic  cavity,  equidistant  from  the  sacrum  and  the  pubic 
bone.  While  on  theoretical  grounds  it  is  claimed  that  the  foetus  in 
its  passage  through  the  pelvic  cavity  follows  this  curved  line,  and 
that  in  the  use  of  the  forceps  traction  should  be  made  according  to  this 
line,  yet  it  is  to  be  borne  in  mind  that  this  view  applies  to  the  static 
pelvis  only,  and  it  will  be  materially  modified  by  the  study  of  the 


32 


PHYSIOLOGY  OF  PREGNANCY. 


dynamic  pelvis.  Fig.  10,  from  Leishrnan,  illustrates  the  generally  ac- 
cepted statement  as  to  the  axis  of  the  birth-canal,  that  is,  of  the  pelvis 
and  its  prolongation  by  the  addition  of  soft  parts  yet  to  be  described. 

While  the  relation  between  the  pelvic  planes  and  the  pelvic  axes  is 
necessarily  unchangeable,  always  remaining  the  same  whatever  the  posi- 
tion of  the  body,  the  relation  of  these  planes  and  axes  to  the  body  and 
to  the  horizontal  line  is  necessarily  changed  by  that  position.  For  ex- 
ample, let  the  subject  be  standing.  The  axis  of  the  body  makes  with 


FIG.  9. 


FIG.  10.1 


INCLINATION  AND  Axis  OF  THE  PELVIS.  Axis  OP  THE  CHILD-BIETH  CANAL. 

r  Rectum,  a  6.  Plane  of  outlet  of  com- 
pleted canal,  e.  Perpendicular  to  plane 
or  axis  of  expulsion. 

a  horizontal  line  an  angle  of  90°.  Now  let  the  body  incline  forward, 
the  angle  is  lessened,  and  the  axis  approaches  the  axis  of  the  inlet ;  now 
let  the  movement  of  the  body  be  reversed,  and  the  axis  of  the  body  is 
thrown  further  from  that  of  the  inlet.  When  the  subject  is  standing, 
the  plane  of  the  outlet  is  nearly  horizontal ;  but  if  she  be  lying  on  her 
back,  the  plane  is  almost  vertical,  and  its  axis  is  nearly  a  horizontal 
line ;  and  from  this  tact  the  practical  rule  has  been  drawn,  that  in  the 

1  This  illustration,  originally  given  by  Dubois,  is  inaccurate  in  two  or  three  respects.  Theantero- 
posterior  diameter  of  the  vulval  outlet  is  represented  as  inferior  to  the  coccy-pubic  diameter,  and 
the  distance  from  the  anus  to  the  point  of  the  coccyx  is  exaggerated,  while  that  from  the  former 
to  the  vulval  opening,  by  some  known  as  the  anterior  perineum,  is  less  than  it  is  during  the 
emergence  of  the  child's  head. 


ANATOMY  OF  THE  PELVIS. 


33 


delivery  of  the  head  through  the  outlet  by  the  forceps  the  pulling  should 
be  in  a  horizontal  line. 

FIG.  11. 


,-H 


D  'K 

RELATIONS  OF  PELVIC  PLANES  AND  Axis  DUE  TO  CHANGES  IN  POSITION  OF  THE  SUBJECT. 
A  B.  Horizontal  line.    0 N.  Antero-posterior  diameter  of  outlet.    FE.  Axis  of  inlet.    CD.  Ver- 
tical line.    HO.  Change  caused  by  leaning  forward.    JK.    By  bending  backward. 

DIFFERENCES  IN  THE  PELVIS  AS  TO  THE  INDIVIDUAL,  SEX,  AGE, 
AND  RACE.  Individual  differences.  As  no  two  faces  are  exactly  the 
same,  so  it  is  probable  that  no  two  pelves  can  be  found  which  do  not 
present  some  differences.  Moreover,  no  pelvis  is  perfect  in  symmetry, 
form,  and  normal  measurements.  It  has  been  said  that  as  the  perfect 
statue  exhibits  the  separate  perfections  of  many  individuals  combined 
in  the  artist's  representation,  so  the  perfect  pelvis  of  the  obstetrician 
represents  a  combination  of  the  perfections  derived  from  various 
pelves. 

Without  any  positive  deformity,  and  without  such  change  in  form 
as  to  present  serious  hindrance  to  labor,  pelves  differ  in  size.  There 
may  also  be  differences  in  the  thickness  of  the  pelvic  bones,  in  their 
relative  smoothness  or  roughness,  in  the  height  of  the  pubic  arch,  in 
the  size  of  the  angle,  in  the  breadth,  length,  and  curvature  of  the 
sacrum,  in  the  depth  of  the  iliac  fossae,  and  in  the  distance  between  the 
iliac  spines  or  iliac  crests.  As  a  rule,  the  development  of  the  pelvis 
corresponds  with  that  of  the  lower  limbs.  It  does  not  follow  that  a 
tall  woman  has  a  small  pelvis ;  its  development  may  be  in  perfect  rela- 
tion to  her  stature ;  if  her  labor  be  protracted,  while  that  of  another, 
whose  stature  is  much  less,  be  brief,  the  occurrence  is  to  be  attributed, 
as  Dubois  has  said,  to  the  fact  that  in  the  latter  the  pelvic  canal  is 
shorter. 

Levret  asserted  that  tlie  circumference  of  the  inlet  was  one-fourth  the  height 
of  the  individual.  Finding  the  latter  it  was  very  easy  to  determine  the  former. 
But  results  have  not  proved  the  correctness  of  the  assertion. 

Weber  sought  to  establish  an  analogy  between  the  head  and  the  pelvis.  As 
heads  present  various  forms,  but  can  be  reduced  to  four  chief  ones— viz.,  oval, 
round,  conical,  and  square — so  the  various  forms  of  the  pelvis  may  be  reduced 
to  the  same  types,  and  these  types  coincide  in  the  individual — that  is,  the  pelvis 
corresponds  in  form  with  the  head.  Not  only  so,  but  certain  measurements  of 


34  PHYSIOLOGY  OF  PREGNANCY. 

the  head  will  represent  pelvic  measurements.  Thus  the  measure  between  the 
zygomatic  arches  represents  that  of  the  transverse  diameter  of  the  superior  strait, 
while  its  antero-posterior  diameter  is  found  by  taking  the  distance  from  the  root 
of  the  nose  to  the  chin. 

As  observed  by  Depaul,  this  theory,  if  it  were  correct,  would  be  of  great  service 
to  the  obstetrician ;  but,  unfortunately,  experience  has  not  sustained  it. 

Kaltenbach1  adopts  the  following  classification  of  pelves : 

1.  The  pelvic  entrance  has  the  shape  of  the  truncated  heart  of  a  playing-card. 

2.  The  pelvic  entrance  is  transverse-oval. 

3.  The  pelvic  entrance  is  round. 

4.  The  pelvic  entrance  is  longitudinal-oval. 

The  pelvis  of  the  Caucasian  belongs  to  the  first  and  second  types  ;  the  pelvis 
of  the  American  aborigines  and  of  the  Australian  negro  belongs  to  the  third 
type ;  while  that  of  the  Bushmen  and  of  the  Malays  is  the  fourth. 

Differences  in  the  sexes.  Verueau2  regards  the  sexual  differences  pre- 
sented by  the  pelvis  as  much  more  positive  than  those  of  any  other  part 
of  the  skeleton,  "  although  many  of  the  differential  characters  com- 
monly given  are  without  value,  such  as  the  form  of  the  ischio-pubic 
foramen,  or  are  entirely  false,  such  as  the  greater  concavity  of  the  sacrum 
in  the  female." 

FIG.  12. 


MALE  PELVIS. 

Of  course,  the  pelvic  bones,  like  the  other  bones  of  the  skeleton,  are 
in  the  male  rougher,  thicker,  stronger,  and  less  delicately  curved  than 
in  the  female.  But  there  are  many  special  characteristics  which  have 
been  fully  studied  by  Verneau.  The  most  important  of  these  will  now 
be  presented.  The  differences  belong  chiefly  to  the  pelvic  cavity,  and 
are  determined  by  the  presence  of  the  uterus.  All  the  dimensions  of 
the  internal  iliac  fossa  are  less  in  the  female,  except  the  distance  from 
the  antero-superior  iliac  spine  to  the  sacro-iliac  joint.  The  fossa  is  more 
shallow  in  the  female.  In  the  male  the  iliac  tuberosity  is  more  devel- 

1  Lebrbuch  der  Geburtshulfe.  2  Op.  cit. 


ANATOMY  OF  THE  PELVIS.  35 

oped  and  projects  further  back.  The  pubic  spines  are  further  apart  in 
the  female.  In  women  all  the  diameters  of  the  inlet  are  greater  than 
in  man.  This  difference  is  especially  marked  as  to  the  transverse  diam- 
eter. The  inlet  in  the  female  pelvis  is  rounder,  due  partly  to  the 
increase  in  the  transverse  diameter  and  to  the  fact  that  the  diameter  is 
placed  further  forward  than  in  the  male  pelvis.  The  great  sciatic  notch 
is  less  open  and  is  deeper  in  man.  In  man,  too,  the  points  of  the  sciatic 
spines  are  in  some  cases  within  the  postero-inferior  iliac  spines,  but  in 
women  they  are  always  without.  The  distance  between  the  sciatic 
spines  is  greater  in  the  female.  The  pubic  arch  is  more  open  in  woman, 

FID.  13. 


FEMALE  PELVIS. 

measuring  75° ;  in  man  only  58°.  In  women  it  is  always  rounded  ; 
the  ischio-pubic  tubercle  is  turned  more  outward,  and  the  ischio-pubic 
ram  us  is  concave  at  its  middle.  In  the  female  the  coccyx  and  sacrum 
are  not  so  high  and  are  more  flattened.  The  ischio-pubic  foramen  is 
not  oval  in  man  and  triangular  in  woman  ;*  in  women  it  is  relatively 
larger  and  more  oblique  outward  and  below.  The  ischia  are  wider 
apart  in  women,  while  all  the  vertical  pelvic  diameters  are  greater  in 
man. 

Thus,  while  there  are  marked  distinctions  between  the  male  and  the 
female  pelvis,  so  that  ordinarily  there  is  no  possibility  of  confounding 
the  one  with  the  other,  yet  in  some  instances2  the  points  of  difference 
are  so  slight  that  it  is  very  difficult  to  decide  whether  a  pelvis  is  male 
or  female. 

Differences  depending  upon  age.  The  pelvis  of  the  foetus  at  term  is 
much  less  developed  than  is  the  upper  portion  of  the  body ;  delivery  is 

1  The  late  Dr.  John  Neill,  of  Philadelphia,  proved  this  fact  more  than  thirty  years  ago,  though 
most  works  upon  anatomy  and  some  upon  obstetrics  still  repeat  the  erroneous  statement  that  the 
foramen  is  oval  in  the  male  and  triangular  in  the  female. 

2  Depaul.  3  Todd's  Cyclopaedia  of  Anatomy  and  Physiology. 


36  PHYSIOLOGY  OF  PREGNANCY. 

therefore  easier.  The  greater  prominence  of  the  abdomen  in  infants 
arises  from  the  imperfect  development  of  the  pelvis  ;  at  birth  the  greatest 
portion  of  the  rectum  and  the  bladder  are  contained  almost  entirely  in 


FIG.  14. 


PELVIS  OF  A  CHILD. 

the  abdominal  cavity,  and  do  not  assume  their  permanent  position  until 
about  the  period  of  puberty.  At  birth  the  false  is  more  developed  than 
the  true  pelvis ;  the  latter  is  straight  and  cylindrical.  According  to 
Wood,3  the  parallelism  of  the  lateral  as  well  as  of  the  anterior  and 
posterior  pelvic  walls  is  sufficiently  marked  and  general  that  it  can  be 
considered  as  a  characteristic  of  the  conformation  of  the  infant  pelvis,  as 
is  found  to  be  the  case  with  most  of  the  lower  animals,  to  which  it  im- 
parts a  square-sidedness.  The  antero-posterior  diameter  of  the  inlet  is 
greater  than  the  transverse  diameter  until  the  age  of  nine  years,  when 
the  other  equals,  then  gradually  exceeds  it.  The  complete  development 
of  the  pelvis,  which  is  not  accomplished  before  twenty  years,  is  largely 
dependent  upon  the  presence  and  activity  of  the  internal  sexual  organs ; 
if  these  are  absent  or  undeveloped,  the  pelvis  fails  to  assume  the  char- 
acteristics of  the  female  sex. 

Differences  dependent  upon  race.  Some  anthropologists  have  regarded 
the  pelvis  next  in  value  to  the  skull  as  the  indication  of  racial  char- 
acteristics. Verneau  suggests  that  it  will  one  day  be  possible,  by  the 
comparison  of  pelves,  to  give,  as  by  the  comparison  of  crania,  a  classi- 
fication of  the  human  race. 

The  relative  proportions  of  the  conjugate  and  transverse  diameters  of 
the  pelvic  inlet  present  remarkable  variations  in  different  races,  though, 
according  to  Professor  Turner,1  the  form  characteristic  of  the  race  is 
more  fixed  in  the  male  than  in  the  female  pelvis,  since  in  the  latter 
there  is,  for  sexual  reasons,  to  a  considerable  extent,  an  approximation 
of  form  in  different  races.  Nevertheless,  the  relation  of  these  diameters 
has  been  chiefly  studied  in  the  female  sex.  In  general,  lessened  trans- 
verse and  increased  conjugate  diameters  of  the  inlet  seem  characteristic 
of  inferior  races.  Thus  Garson,2  incorporating  the  measurements  given 

1  Journal  of  Anatomy  and  Physiology,  vol.  xx.,  1885.  2  Ibid.,  vol.  xvi.,  1882. 


AXATOMY  OF  THE  PELVIS.  37 

by  Verneau  with  those  made  by  himself,  obtained  an  a\7erage  conjugate 
of  106  millimetres  in  49  European  pelves,  and  a  transverse  of  134.5  ; 
while  in  7  Australian  pelves  the  average  conjugate  was  108.6,  and  the 
transverse  120.  Verneau  found  that  the  pelvis  of  the  Egyptian  and 
that  of  the  Laplander  were  each  smaller  than  that  of  the  French  woman. 
In  no  people,1  however,  has  it  been  found  that,  where  a  sufficient 
number  of  pelves  have  been  examined  to  make  a  just  average,  the  con- 
jugate exceeds  the  transverse  diameter.  Everywhere  the  form  of  the 
female  pelvis  indicates  its  part  in  labor  when  the  foetus  is  perfectly 
developed. 

It  is  not  improbable  that  a  definite  relation  between  the  size  and  form  of  the 
foetal  head  and  those  of  the  pelvis  will  be  proved  to  exist  in  different  races.  With 
the  progress  of  a  race,  with  its  greater  intellectual  and  moral  development,  it  is 
possible  that  there  is  a  development  pari  passu  of  the  pelvis.  Broca  has  shown 
that  the  Parisian  of  to-day  has  a  greater  cerebral  capacity  than  the  Parisian  of 
the  twelfth  century ;  and  that  the  skull  of  the  latter  had  a  greater  capacity  than 
the  skull  of  the  Greek  of  the  Macedonian  period,  skulls  of  this  period  exhumed 
at  Athens  within  a  few  years  showing  a  decided  inferiority.  Now  it  is  at  least  a 
probable  conclusion  that  if  the  head  has  thus  increased  in  size,  the  bony  canal 
through  which  it  is  transmitted  at  birth  has  undergone  a  corresponding  increase. 
Nevertheless,  Spiegelberg2  has  remarked  that  "  the  opinion  that  the  further  north 
a  race  is  living  the  larger  the  pelvis,  and  also  the  other  assumption,  that  an 
increase  in  size  of  the  pelvis  occurs  with  the  increase  of  civilization  of  a  race,  are 
not  proved ;  it  would  be  more  correct  to  state  that  favorable  conditions  of  nutri- 
tion and  activity  are  the  basis  of  a  well-formed  pelvis." 

Ploss3  states  that  the  habits  and  customs  of  a  people  and  their  mode  of  life 
undoubtedly  have  a  certain  influence  in  the  formation  of  the  prevalent  pelvic 
type.  The  general  nutrition,  more  particularly  the  supply  of  bone-forming 
material,  is  of  importance.  G.  Fritsch  found  that  a  dwarfed,  poorly  developed 
pelvis  bore  a  close  relation  to  the  general  system  of  the  Bushwomen  and  Hot- 
tentots. The  pelves  of  the  South  African  races  present  neither  the  typical  male 
nor  female  form,  but  rather  a  combination  of  the  male  and  female  pelvis,  as  a 
rule  approaching  the  male  form.  This  results  to  some  degree  from  the  unfavor- 
able conditions  in  which  these  people  live,  the  entire  skeleton  never  attaining 
that  perfection  found  in  a  civilized  people.  It  is  asserted  that  the  pelves  of 
negresses  born  in  America  correspond  more  nearly  to  those  of  the  European 
type,  improvement  of  the  general  environment  leading  to  better  development  of 
the  entire  osseous  system. 

SOFT  PARTS  OF  THE  PELVIS.  The  structures  which  line  the  pelvis 
and  those  which  chiefly  make  its  inferior  wall  are  called  soft  parts. 

On  either  side  of  the  upper  pelvis  the  iliacus  and  the  psoas  muscles 
are  placed.  The  iliacus  covers  the  entire  iliac  fossa ;  it  arises  from  the 
anterior  two-thirds  of  the  iliac  crest,  from  the  anterior  iliac  spines  and 
the  space  intervening,  from  the  sacrum,  from  the  sacro-iliac  joint,  and 
from  the  ilio-lumbar  ligament,  and  is  inserted  into  the  external  border 
of  the  tendon  of  the  psoas.  The  psoas  muscle  has  its  origin  from  the 
sides  of  the  bodies  and  the  transverse  processes  of  the  four  upper 
lumbar  vertebrae,  and  from  the  last  dorsal,  descends  to  the  base  of  the 
sacrum,  fills  up  the  depression  on  each  side  of  the  promontory,  and 
thick,  spindle-shaped  passes  along  the  innominate  line,  receives  the 
fibres  of  the  iliacus,  then  goes  out  of  the  pelvis  between  the  ilio-pectineal 
eminence  and  the  inferior  iliac  spine,  to  be  inserted  into  the  entire  sur- 
face of  the  less  trochanter. 

1  Professor  Turner.  2  Lehrbuch  der  GeburtshUlfe. 

3  Das  Weib  in  der  Natur  und  Viilkerkunde. 


38 


PHYSIOLOGY  OF  PREGNANCY. 


An  apoueurosis  called  the  iliac  fascia  covers  the  iliacus  and  the  psoas 
muscles ;  it  divides  into  two  layers,  and  thus  furnishes  a  sheath  for  the 
iliac  vessels  and  lymphatic  ganglia.  The  external  iliac  artery  and  vein 
lie  upon  the  internal  border  of  the  psoas.  The  lumbar  plexus  is  placed 
in  the  substance  of  the  muscle ;  its  most  important  branch,  the  crural, 


THE  PELVIS,  WITH  SOFT  PARTS.    (Bladder,  rectum,  uterus  and  its  appendages  having  been 

removed.) 

A.  Aorta.  B.  Primary  iliac  of  left  side.  C.  External  iliac  of  left  side.  D.  Internal  iliac  of  left 
aide  E.  Inferior  vena  cava.  F.  Primary  iliac  vein  of  left  side  G.  External  iliac  vein  of  left 
side.  H.  Sacral  insertion  sacro-sciatic  ligament.  I.  Sacro-vertebral  angle.  J.  Quadratus  lum- 
borum,  K  K.  Psoas  muscles.  L  L.  Iliac  muscles.  M  M.  External  obturator  muscles.  X.  Pubic 
arch.  P  P.  Great  trochanters.  R  B.  Section  of  the  muscles  of  the  abdominal  wall. 

after  emerging  from  the  muscle,  lies  between  it  aod  the  iliac  muscle, 
and  then  passes  from  the  pelvis  below  Poupart's  ligament.  It  has  been 
suggested  that  the  presence  of  these  nerves  in  the  psoas  explains  the 
violent  lumbar  pains  which  women  suffer  in  labor. 

So,  too,  the  pain  felt  at  the  inner  part  of  the  thighs,  when  the  head 
of  the  foetus  descends  through  the  inlet,  is  explained  by  pressure  on  the 


AX  ATOMY  OF  THE  PELVIS.  39 

obturator  nerve  at  the  base  of  the  sacrum  as  it  passes  under  the  apo- 
neurosis,  this  nerve  furnishing  branches  to  the  adductors. 

The  psoas  and  the  iliacus  muscles  acting  from  above  flex  and  abduct 
the  thighs;  from  below  and  on  both  sides  they  incline  the  lower  portion 
of  the  spine  and  pelvis  forward. 

The  iliacus  muscle  serves  as  a  cushion  upon  which  the  gravid  uterus 
rests.  The  psoas  lessens  the  obliquity  of  the  iliac  bone  and  makes  the 
slope  to  the  superior  strait  more  uniform.  The  two  psoas  muscles  and 
the  vessels  at  their  internal  border  lessen  the  iulet.  The  diminution  of 
the  oblique  diameters  is  only  about  one-eighth  of  an  inch  in  each,  but 
that  of  the  transverse  is  three-fifths  of  an  inch,  or  1.5  of  a  centimetre. 
The  diminution  of  the  last  diameter  may  be  so  great  when  the  muscle 
is  contracting  as  to  prevent  the  entrance  of  the  foetal  head. 

In  the  pelvic  cavity  the  pubic  joint  and  the  median  surface  of  the 
sacrum  and  of  the  coccyx  have  no  muscular  covering ;  but  on  each  side 
the  obturator  internus  and  the  pyriformis  muscles  are  found,  the  tendon 
of  the  former  passing  out  of  the  pelvis  through  the  less,  the  latter 
through  the  great  sciatic  foramen,  notably  contributing  to  the  closure 
of  these  openings.  The  nerves  of  the  sacral  plexus  lie  in  front  of  the 
pyriformis.  The  bladder  is  placed  in  the  anterior  part  of  the  pelvic 
cavity,  behind  the  pubis,  but  its  position  varies  according  as  full  or 
empty.  The  rectum  enters  the  pelvic  cavity  in  front  of  the  left  sacro- 
iliac  joint — thus  slightly  lessening  the  left  oblique  diameter  of  the  inlet — 
passes  obliquely  to  the  middle  of  the  anterior  surface  of  the  sacrum, 
and  then  descends  in  front  of  the  sacrum  and  coccyx.  The  soft  parts 
in  the  cavity  make  but  slight  change  in  its  capacity.  A  full  bladder  or 
rectum  may  hinder  the  descent  of  the  head  in  labor,  and  therefore  the 
obstetrician  is  careful  that  each  organ  is  emptied. 

THE  PELVIC  FLOOR.  Skin,  connective  tissue,  muscles,  and  layers 
of  strong  fascia  unite  to  form  the  pelvic  floor  which  contributes  to  the 
support  of  pelvic  and  abdominal  viscera,  and  which  at  the  same  time 
is  so  formed  that  it  may  be  temporarily  opened  almost  to  the  bounds 
of  the  bony  outlet,  to  permit  the  passage  of  the  mature  fcetus.  This 
pelvic  floor — diaphragm  or  inferior  wall — is  perforated  by  the  urethra, 
vagina,  and  rectum ;  but  these  canals  are  closed,  the  first  two  by  the 
accurate  apposition  of  their  walls,  and  the  last  by  the  contraction  of  the 
anal  sphincter,  unless  when  in  functional  exercise. 

On  examining  the  pelvic  floor  from  within  out  we  find,  first,  the 
superior  pelvic  aponeurosis,  this  apoueurosis  being  more  or  less  covered, 
as  all  the  pelvic  organs  are,  by  peritoneum.  It  is  simply  the  united 
fascia  of  the  pyriform,  internal  obturators,  ischio-coccygeal,  and  levator 
aui  muscles ;  it  is  attached  to  the  posterior  part  of  the  pubic  joint,  to 
the  upper  part  of  the  sciatic  notch,  and  to  the  sacrum  at  the  inlet,  and 
it  is  continuous  with  the  iliac  fascia.  Beneath  this  aponeurosis  are 
placed  the  levatores  ani  and  the  two  ischio-coccygeal  muscles.  The 
first  has  its  origin,  on  either  side,  from  the  pubic  ramus,  the  pelvic 
fascia,  the  ischial  spine,  and  the  less  sciatic  ligament ;  its  fibres  are 
inserted,  first,  at  the  base  of  the  bladder,  then  in  the  vaginal  walls,  and 
in  the  coats  of  the  rectum  near  the  anus ;  the  posterior  fibres  are  in- 
serted in  a  raphe  extending  from  the  tip  of  the  coccyx  to  the  anus. 


40  PHYSIOLOGY  OF  PREGNANCY. 

The  broad  muscular  band  thus  formed  makes  a  diaphragm  concave 
above,  convex  below,  for  the  pelvic  cavity.  It  raises  the  anal  orifice 
and  dilates  it  in  defecation. 

Budin,  Progrts  Medical,  states  that  in  exceptional  cases  the  muscular  fibres  of 
the  levator  ani  in  the  female  may  undergo  remarkable  development,  so  that  its 
contractions  can  be  readily  felt  by  the  finger  in  the  vagina ;  in  some  cases  making 
a  tightly  constricting  circle,  in  other  cases  an  elevation  of  the  posterior  wall  of 
the  vagina,  so  that  it  is  drawn  toward  the  anterior  wall.  In  either  case  certain 
results  may  follow,  such  as  difficulty  or  impossibility  of  sexual  intercourse  and 
delay  in  the  escape  of  the  foetus. 

FIG.  16. 


e 

UROGENITAL  AND  ANAL  KEGIONS  IN  WOMAN. 

1.  Gluteus  maximus.  2.  Levator  ani.  3.  Superficial  transverse  perineal  muscle.  4.  Profound 
transverse  perineal  muscle.  5.  Vaginal  sphincter  muscle.  6.  External  anal  sphincter.  7.  Fas- 
ciculi of  vaginal  sphincter  passing  to  the  perineal  body.  9.  Ischio-cavernosus  muscle.  10-  Clitoris. 
11.  Bulb  of  the  vestibule. 

Dickinson  {American  Journal  of  Obstetrics,  September,  1889)  contributes  a 
well-illustrated  study  of  the  anatomy  and  action  of  the  levator  ani  muscle.  By 
introducing  cylinders  of  modelling  wax  into  the  vagina  and  having  the  patient 
voluntarily  contract  the  muscle  by  straining,  he  studied  the  contractions,  graph- 
ically, with  the  following  results :  The  distance  from  the  vaginal  orifice  to  the 
inner  edge  of  the  levator  averages  less  than  half  an  inch  (1.2  cm.).  The  double 
band  of  the  muscle  is  always  sharply  defined.  The  more  the  levator  is  stretched 
the  closer  the  strong  edges  of  the  horizontal  belly  are  brought  together.  The 
contraction  of  the  muscle  crowds  the  penis  against  the  cervix  during  coition ; 
the  vaginal  outlet  remains  quiet,  while  the  upper  portion  rises  fifteen  or  twenty 
degrees  toward  the  brim.  A  dynamometer  test  of  the  strength  of  the  muscle 
gave  an  average  of  ten  pounds,  occasionally  twenty-seven.  It  is  especially  strong 
in  muscular  and  erotic  women,  in  those  with  wide  pelves,  and  in  those  suffering 
from  painful  lesions  about  the  vulva  and  vagina. 

He  adds  two  cases  of  laceration  of  the  pelvic  floor  which  illustrate  the  efficiency 
of  the  muscle  in  preventing  rectocele,  and  has  collected  five  cases  of  labor  delayed 
by  the  spasmodic  contraction  of  this  muscle,  to  which  he  adds  one  from  his  own 
observation. 

The  ischio-eoccygeus  is  in  the  same  plane  as  the  levator  ani,  lying 
between  it  and  the  pyriforrn ;  it  is  triangular  in  shape,  the  base  being 


AS  ATOMY  OF  THE  PELVIS.  41 

attached  to  the  border  of  the  coccyx  and  of  the  lower  part  of  the 
sacrum,  and  the  apex  to  the  ischial  spine.  The  two  ischio-coccygeal 
muscles  hinder  the  backward  movement  of  the  coccyx.  They,  with 
the  anal  levators,  make  the  deep  muscular  layer  of  the  perineal  floor, 
and  beneath  the  plane  they  form  the  anal  sphincter  is  placed.  This 
muscle  has  the  form  of  an  ellipse,  the  long  diameter  being  antero- 
posterior ;  it  arises  by  muscular  fibres  attached  to  the  last  bone  of  the 
coccyx  and  subjacent  skin  ;  these  then  form  on  each  side  of  the  anus  a 
semicircular  baud,  and,  converging  in  front,  are  inserted  in  the  perineal 
body.  Beneath  the  sphincter  is  the  skin. 

The  part  of  the  pelvic  floor  thus  described  is  called  the  posterior 
perineal  region ;  it  is  triangular  in  form,  the  apex  of  the  triangle  being 
at  the  tip  of  the  coccyx  and  its  base  a  line  between  the  ischial  tuberosi- 
ties.  The  anterior  perineal  region  is  included  between  the  line  just 
mentioned  and  the  pubic  joint.  The  pelvic  floor  is  here  formed  ot 
skin,  fasciae,  and  muscles.  The  latter  are  seven,  viz.,  one  vaginal 
sphincter  and  two  ischio-cavernosi,  two  transverse  perineal  and  two 
ischio-bulbous.  The  vaginal  sphincter  arises  from  the  perineal  body, 
surrounds  the  vaginal  orifice,  and  is  inserted  upon  the  body  of  the 
clitoris  and  its  suspensory  ligament.  The  ischio-cavernosus  has  its 
origin  on  either  side  from  the  ischial  tuberosity  and  from  the  ischio- 
pubic  ramus,  and  is  inserted  by  two  tendinous  expansions,  one  above 
and  the  other  below  the  union  of  the  crura  of  the  clitoris.  The  trans- 
verse perineal  muscles  arise  from  the  ischial  tuberosities  below  the  pre- 
ceding, and  are  inserted  in  the  perineal  body.  The  ischio-bulbous 
muscle  passes  ft'om  the  ischium  on  each  side  to  the  corresponding  bulb 
of  the  vagina.  Three  aponeurotic  planes  are  found  in  the  anterior 
perineal  region — the  deep,  the  middle,  and  the  superficial.  Between  the 
last  two  the  muscles  just  described  are  placed. 

PERINEUM.  This  part  of  the  pelvic  floor  is  of  especial  interest  to 
the  obstetrician.  It  is  bounded  by  the  anus  behind,  by  the  ischial 
tuberosities  on  the  sides,  and  by  the  vulval  opening  in  front.  These 
limits  apply  to  its  external  surface  only.  It  has  also  a  vaginal  and  a 
rectal  surface,  so  that  a  median  section  of  the  perineum  would  in  form 
resemble  a  spherical  triangle. 

The  distance  from  the  anal  to  the  vulval  opening  is  about  three 
centimetres,  or  a  little  more  than  an  inch,  according  to  Spiegelberg. 
Foster1  found  that  in  the  parous  this  measurement  was  rather  less  than 
an  inch,  2.7  centimetres,  but  in  the  nulliparous  somewhat  more  than 
an  inch.  The  hypertrophy  of  pregnancy  may  increase  this  measure- 
ment to  an  inch  and  a  half,  or  four  centimetres.  In  labor  the  perineum 
may  be  so  stretched  by  the  presenting  part  as  to  measure  five  inches 
and  a  half,  or  fourteen  centimetres.  It  is  generally  held  that  this  dis- 
tensibility  depends  "upon  an . irregularly  limited  mass  of  elastic  tissue 
and  muscular  fasciculi  situated  midway  between  the  posterior  commis- 
sure of  the  vulva  and  the  anus,"  known,  since  the  investigations  ot 
Henle  and  Savage,  as  the  perineal  body.  According  to  Savage,2  the 
greatly  stretched  perineal  body  is  the  final  covering  of  the  presenting 

1  American  Journal  of  Obstetrics,  1880.  2  Anatomy  of  the  Female  Pelvic  Organs. 


42  PHYSIOLOGY  OF  PREGNANCY. 

part.  In  very  fat  women  the  perineum  does  not  yield  readily  in  labor, 
and  hence  the  liability  to  its  rupture ;  while  in  some  other  patients  it 
yields  too  readily,  and  its  anterior  margin  is  prolonged  toward  the 
pubic  arch,  while  its  central  portion  is  so  thinned  that  it  may  be  per- 
forated by  the  child's  head,  that  is,  a  central  rupture  occur. 

PUBIC  AND  SACRAL  SEGMENTS  OF  THE  PELVIC  FLOOR.  The 
pelvic  floor,  in  its  relations  to  labor,  is  divided  by  Hart1  into  two  parts, 
designated  respectively  the  pubic  and  the  sacral  segment.  The  anterior 
vaginal  wall  is  the  posterior  boundary  of  the  former  segment,  and  the 
posterior  vaginal  wall  the  anterior  boundary  of  the  latter  segment.  In 
labor  the  anterior  segment  is  drawn  up,  while  the  sacral  segment  is 
forced  down  ;  and  thus,  as  two  doors  meeting  at  their  free  border  are 
opened,  the  one  by  drawing  it  toward  the  passenger,  the  other  by 
pushing  it  from  him,  so  the  pelvic  floor  is  opened  for  the  transmission 
of  the  foetus. 

FIG.  17. 


ANTEEO-POSTERIOR  SECTION  OF  THE  APONEUROSES  OF  THE  PERINEAL  FLOOR. 
S.  Sacrum.    A  P.  Pelvic  aponeurosis.    B.  Deep  perineal  aponeurosis.    C.  Middle  perineal  apo- 
neurosis.    D.  Superficial  perineal  aponeurosis.    E.  Connective-tissue  layer  which  covers  the  lower 
surface  of  the  levator  ani  behind  the  bis-ischiatic  line,  where  it  is  fused  with  the  posterior  border 
of  the  deep  perineal  aponeurosis.    P.  Pubis. 

The  vagina  passes  through  the  pelvic  floor  parallel  to  the  conjugate 
of  the  inlet. 

THE  DYNAMIC  PELVIS.  From  the  parallelism  of  the  vagina,  as  it 
passes  through  the  pelvic  floor,  with  the  antero-posterior  diameter  of  the 
inlet,  it  necessarily  follows  that  if  the  presenting  pole  of  the  foetus  enters 
the  inlet  in  a  line  perpendicular  to  its  plane,  the  emergence  of  that  pole 
from  the  vagina  will  be  in  a  line  perpendicular  to  the  prolonged  previous 
line.  Hence,  according  to  the  view  of  Boissard  and  some  others,  a 
curved  line  does  not  represent  the  line  of  direction  taken  by  the  pre- 

1  Female  Pelvic  Anatomy. 


ANATOMY  OF  THE  PELVIS. 


43 


senting  part  in  passing  through  the  birth-canal,  or  the  dynamic  as  dis- 
tinguished from  the  osseous  or  static  pelvis.  Further,  as  has  been 
shown  by  Fabbri  and  Pinard,1  a  cast  of  the  entire  pelvis — that  is,  of  the 
bony  pelvis  with  the  membranous  canal  formed  at  the  expense  of  the 
soft  parts,  a  membranous  canal  channelled  in  all  the  thickness  of  the 
perineal  floor,  which  is  greatly  developed  at  the  period  of  expulsion, 

FIG.  18. 


connected  with  the  former — will  make  it  evident  that  the  completed 
pelvic  cavity  is  not  a  curved  but  chiefly  a  cylindrical  canal.  This 
cavity  has  its  fund  us  at  the  coccyx,  and  the  presenting  part  of  the  foetus 


FIG.  19. 


A.  Inferior  external  face  of  the  levatorani.    B.  Precoccygeal  fasciculi  divided  and  separated. 
C.  Great  sacro-sciatic  ligament. 

descends  in  a  straight  line  to  the  fundus.  The  cavity  is  there  closed, 
but  presents  an  opening  upon  the  anterior  wall,  and  the  line  of  direction 
now  becomes  one  nearly  perpendicular  to  that  of  descent. 

THE  GENITAL  PORTION  OF  THE  BIRTH-CANAL.     By  this   name 
Farabeuf  and  Varnier2  call  that  portion  of  the  canal  beginning  at  the 

1  Boissard :  De  la  forme  de  1'Excavatlon  Pelvienne.    Paris,  1884. 

2  Farabeuf  and  Varnier :  Introduction  a  1'fitude  clinique  et  a  la  pratique  des  Accouchements. 


44  PHYSIOLOGY  OF  PREGNANCY. 

outlet  of  the  bouy  pelvis  and  ending  with  the  vulval  orifice,  traversed 
by  the  foetus  after  passing  out  of  the  pelvic  cavity.  They  call  it,  by 
antithesis,  the  soft  or  dilatable  pelvis.  It  is  funnel-shaped,  the  opening 
of  this  funnel  being  formed  by  the  periueal  muscular  floor,  that  is,  of 
the  levatores  ani  and  of  the  ischio-coccygeal  muscles.  On  each  side 
the  soft  basin  is  attached  to  the  contour  going  from  the  lowest  part  of 
the  body  of  the  pubic  bone  to  the  point  of  the  sacrum  connected  with 
the  ischial  spine,  and  the  coccyx  making  a  part.  (See  Fig.  19,  in 
which  the  "diaphragm  of  the  muscular  floor  of  the  pelvis,  concave 
above,  infundibuliform,  and  opening  by  a  large  median  slit,"  is  shown.) 

FIG.  20. 


VERTICAL  MEDIAN  SECTION  OF  PELVI-GENITAL  CANAL.  (FAKABEUF  and  VERNIER.) 
The  muscular  fibres  of  the  coccy-perineal  levator.  C.  Ischio-coccygeal.  R.  Chief  fasciculi  at 
the  point  of  the  coccyx.  R'  R'.  Other  fasciculi  of  the  levator  separated  in  consequence  of  elonga- 
tion of  their  line  of  perineal  insertion.  6.  Bladder.  8.  Pubic  symphysis.  c  I.  Clitoris,  v.  Con- 
strictor of  the  vulva.  /.  Fourchette.  a  p.  Anterior  perineum,  a.  Anus  opened,  pp.  Posterior 
perineum,  r.  Rectum  flattened,  c.  Coccyx  pushed  back.  Sacr.  Point  of  sacrum. 

"This  cleft  may  be  called  pubo-coccygeal,  for  the  greater  part  of 
the  fasciculi  of  the  levator  muscle  is  concentrated  toward  the  coccyx." 
Its  antero-posterior  dilatability  is  limited  by  the  degree  of  the  retro- 
flexibility  of  the  coccyx.  In  front  its  transverse  dilatability  permits 
it  to  equal  the  size  of  the  bony  pubic  arch  upon  which  it  is  inserted. 
Behind,  it  may  be  greater ;  but  the  fatty  mass  of  the  ischio-rectal  fossa 
rarely  permits  the  levator  aui  to  be  pressed  upon  the  great  sacro-sciatic 
ligament  and  the  ischial  tuberosity. 


ANATOMY  OF  THE  PELVIS. 


45 


"  Dilated  by  the  foetal  part  this  cleft  gains  in  length  posteriorly,  and 
in  breadth  at  each  side.  It  remains  more  extensive  autero-posteriorly 
than  transversely." 

"  Examined  when  the  fcetal  pole  appears  at  the  vulva,  the  perineo- 
vulvar  passage  forms  the  curved  part  of  the  pelvi-genital  canal.  As  in 
the  pelvic  cavity,  the  anterior  wall,  the  subpubic,  is  short,  the  posterior, 
perineal,  very  long."  (Fig.  126,  page  371,  second  edition.) 

"  This  extends  from  the  base  of  the  coccyx  to  the  vulval  fourchette, 
and  is  greatly  stretched ;  it  may  be  15  centimetres,  5.92  inches." 
"  The  pelvi-vagiual  or  pelvi-genital  canal  which  the  foetus  passes 
through  is  thus  strongly  curved,  and  embraces  the  symphysis  with  its 
concavity,  like  the  curvature  of  a  male  vesical  sound." 


This  Is  Fig.  20  (vertical  median  section  of  the  pelvi-genital  canal)  placed  in  the  obstetric  position. 
A.  Axis  of  the  superior  strait  and  of  the  pelvic  cavity.  G.  Pubic  symphysis.  B.  Point  of  sacrum. 
C.  Coccyx  pushed  baek.  D.  Axis  of  entrance  into  inferior  strait.  E.  Axis  of  escape  from  inferior 
strait.  F.  Axis  of  the  vulval  strait. 

In  explaining  the  axes  of  the  entire  birth-canal  the  authors  state  the 
conclusions  to  be  drawn  from  a  study  of  the  subjoined  illustration  are 
that,  :f  the  accoucheur  introduce  his  hand  so  as  to  grasp  the  presenting 
part  of  the  foetus,  he  will  first  draw  below,  toward  his  feet,  in  order  to 
bring  the  part  through  the  superior  strait  and  descend  into  the  pelvic 
cavity ;  subsequently  he  will  still  draw  below,  but  toward  his  knees,  in 
order  that  it  shall  enter  and  escape  the  inferior  strait ;  finally,  more 
and  more  upward,  toward  his  head,  for  it  to  pass  out  of  the  vulval 
ring. 


CHAPTEK    II. 


FIG.  22. 


THE   FEMALE   SEXUAL   ORGANS. 

THE  female  sexual  organs  are  divided  into  those  of  generation  and 
those  of  lactation.     The  organs  of  generation  are  the  external  and  the 

internal. 

THE  EXTERNAL  ORGANS  OF 
GENERATION.  These  are  included 
in  the  word  pudendum  or  puden- 
dum muliebre.  Vulva1  is  often 
used  as  a  synonym,  though  this 
term  does  not,  strictly  speaking, 
include  the  mons  veneris. 

MONS  VENERIS.  This  is  the 
upper  part  of  the  pudendum,  and 
is  bounded  above  by  the  hypogas- 
trium,  by  the  groin  on  either  side, 
and  by  the  greater  lips  below.  It 
measures  three  inches  from  side 
to  side,  and  two  inches  from  above 
down — 7.6  by  5  cm.  A  very  large 
number  of  hair-follicles  and  seba- 
ceous glands  are  found  in  the  skin 
covering  the  mons.  The  growth  of 
hair  occurs  at  puberty,  and  hence 
the  name  for  the  bony  part  upon 
which  the  mons  is  placed.  Beneath 
the  skin  there  is  a  thick  layer 
of  connective  and  adipose  tissue, 
which  is  traversed  by  fibres  of 
elastic  tissue  passing  in  various 
directions.  Some  of  these  fibres 
are  connected  with  the  superficial 
abdominal  fascia.  Muscular  fibres 
from  the  round  ligament  also  enter 
this  organ. 

LABIA  MAJORA.  The  greater 
lips,  or  alse,2  are  two  folds  of  skin 
passing  from  the  median  line  and 
just  below  the  mons  veneris  on  each  side  of  the  vulval  entrance  to  meet 
in  the  middle  and  anterior  part  of  the  perineum.  Their  junction  above 

1  Vulva  is  from  the  word  volvo,  and  was  originally  spelled  volva ;  it  meant  the  womb,  or  covering 
of  the  unborn  animal.    Vulva  has  no  connection  with  valva,  though  the  latter  is  derived  from  the 
same  root. 

2  Winslow,  in  his  Anatomy,  says :  "  The  ancients  called  the  lateral  parts  of  the  cavity  ate,  which 
is  a  more  proper  name  than  that  of  Idbia,  commonly  given  them." 


VULVA  OF  THE  VIRGIN. 

1.  Greater  lip  of  right  side.  2.  Fourchette.  3. 
Small  lip.  4.  Clitoris.  5.  Urethral  orifice.  6. 
Vestibule.  7.  Orifice  of  the  vagina.  8.  Hymen. 
9.  Orifice  of  the  vulvo-vaginal  gland.  10.  An- 
terior commissure  of  greater  lips.  11.  Anal 
orifice. 


THE  FEMALE  SEXUAL  ORGANS.  47 

is  about  half  an  inch,  or  one  centimetre  and  a  half,  above  the  clitoris, 
and  is  the  anterior  commissure.  Their  union  below,  or  posterior  com- 
missure, is  simply  a  fold  of  cutaneous  tissue,  marking  the  anterior  mar- 
gin of  the  perineum,  and  is  called  the  fourchette.  The  depression  be- 
tween the  fourchette  and  the  hymen  is  the  navicular  fossa. 

The  external  surfaces  of  the  labia  majora  are  convex  and  somewhat 
darker  than  the  adjacent  skin.  They  have  an  abundant  supply  of  hair- 
follicles  and  of  sebaceous  and  sudoriparous  glands.  The  growth  of 
hair,  which,  like  that  upon  the  mons  veneris,  occurs  at  puberty,  is 
remarkable  at  the  upper  part,  but  lessens  as  the  labia  descend  to  the 
perineum.  The  internal  surfaces  of  these  organs  are  plane,  somewhat 
pink  or  rose-colored,  and  in  children,  in  virgins,  and  in  the  fleshy  are 
in  direct  contact ;  but  in  those  who  have  borne  many  children,  in  the 
old,  and  in  the  emaciated  are  separate,  flabby,  and  relaxed,  seeming  like 
folds  of  dark  and  wrinkled  skin,  and  expose  the  vulval  entrance.  The 
anterior  borders  are  round  and  prominent,  but  become  flattened  and  less 
distinct  as  they  approach  the  posterior  commissure.  The  posterior 
borders  are  attached  to  the  ischio-pubic  rami.  Beneath  the  skin  of  the 
external  surfaces  and  anterior  borders  of  the  labia  there  are  found 
smooth  muscular  fibres  forming  that  which  Sappey  has  described  as  the 
dartos  of  the  female,  which  is  analogous  to  the  dartos  of  the  male.  Each 
labium  contains,  according  to  Broca,  a  pyriform  pouch,  formed  of  elastic 
fibres,  its  large  extremity  being  toward  the  posterior  commissure,  while 
its  small  end  is  directed  to  the  inguinal  canal.  Sappey  has  described  it 
as  the  elastic  apparatus  of  the  labia.  The  round  ligament  of  the  uterus, 
the  analogue  of  the  gubernaculum  of  Hunter,  terminates  in  the  labium 
majus.  In  some  cases  a  prolongation  of  the  peritoneum,  forming  the 
canal  of  Nuck,  which  is  normally  closed  before  birth,  accompanies  the 
ligament,  and  an  accumulation  of  fluid  in  this  canal  may  occur  analo- 
gous to  hydrocele  of  the  cord,  and  frequently  described  as  hydrocele  of 
women.  Connective  and  adipose  tissue,  bloodvessels,  lymphatics,  and 
nerves  complete  the  structure  of  the  labia.  The  superior  commissure 
of  the  labia  forms  an  arch  over  the  clitoris  and  partially  covers  and 
protects  this  organ. 

LABIA  MINOEA.  Two  folds  of  skin  are  found  at  the  inner  surface 
of  each  labium  majus,  beginning  about  the  middle  of  the  base  of  each 
greater  lip,  and  are  called  the  lesser  lips  or  nymphse.  They  extend 
above  nearly  to  the  clitoris,  then  each  bifurcates ;  the  lower  divisions 
meet  below  the  clitoris,  but  the  upper,  which  are  the  larger,  unite  above 
this  organ,  forming  the  hood  or  prseputium  clitoridis.  The  nymphas 
are  rose-colored  and  are  without  hair-bulbs,  sudoriparous  glands,  or 
muscular  fibres.  A  layer  of  connective  tissue,  containing  numerous 
elastic  fibres  and  bloodvessels,  unites  the  folds  of  skin  of  each  nympha. 
The  labia  minora  are  remarkable  for  their  sensitiveness  and  for  their 
rich  supply  of  sebaceous  follicles.  There  are,  according  to  Sappey,  one 
hundred  of  these  glands  to  every  square  centimetre  of  the  external  sur- 
face, and  one  hundred  and  twenty  to  one  hundred  and  fifty  to  every 
square  centimetre  of  the  internal  surface.  While  remarkably  sensitive 
and  thus  concerned  in  copulation,  the  nympha?  are  not  erectile  organs. 
In  parturition  they  contribute  to  the  enlargement  of  the  vulval  orifice. 


48  PHYSIOLOGY  OF  PREGNANCY 

The  size  of  these  organs  is  different  at  different  ages.  At  birth  they 
are  quite  prominent,  because  of  the  little  development  of  the  labia 
majora;  at  puberty  the  notable  growth  of  the  latter  causes  them  to  be 
hidden,  though  they  also  increase  in  size  at  that  time,  unfolding,  accord- 
ing to  the  comparison  of  the  Swedish  botanist,  Linnseus,  like  the  petals 
of  a  flower.  They  may  be  elongated  by  traction,  and  thus  lengthened 
and  hypertrophied,  measuring  some  five  inches,  12.6  centimetres,  or 
more,  forming  what  has  been  called  the  apron  of  the  Hottentots.  If 
projecting  beyond  the  labia  majora,  they  become  brownish  —  in  negresses, 
for  example,  they  are  then  as  dark  as  the  skin.  They  were  supposed  to 
direct  the  flow  of  the  urine,  and  hence  received  the  name  uymphaB. 

Among  some  of  the  Orientals  the  nymphse  are  quite  large,  hindering  the 
entrance  of  the  penis,  and  their  partial  excision  was  the  circumcision  of  females. 
Cuvier  states  that  in  the  sixteenth  century  missionaries  in  Abyssinia  persuaded 
their  converts  to  abandon  the  custom,  but  as  girls  could  no  longer  find  husbands 
the  Pope  authorized  a  return  to  it. 

THE  CLITOKIS.'  Two  crura,  or  branches  —  one  attached  to  each 
ischio-pubic  ramus  —  ascend  and,  converging,  meet  in  front  of  the 
pubic  joint  to  form  the  body  of  the  clitoris,  this  body  consisting  of  two 
corpora  cavernosa,  analogous  to  the  corpora  cavernosa  of  the  penis.  It 
is  fastened  to  the  anterior  and  inferior  part  of  the  pubic  joint  by  a  sus- 
pensory ligament.  Sappey  asserts  that  from  its  connection  with  the 
pubic  symphysis  and  with  the  uymphse  change  in  its  position  or  in  its 
curvature  is  impossible.  Its  anterior  portion,  small  and  rounded,  cov- 
ered by  the  prepuce  above  and  on  each  side,  below  by  the  inferior  layers 
of  the  dividing  nymphse,  is  improperly  called  the  glans  —  it  has  no  ori- 
fice, no  glandular  structure.  The  dimensions  of  the  clitoris  vary  in 
different  subjects,  but,  according  to  de  Sine"ty,  the  average  length  is 
about  three  centimetres,  or  a  little  more  than  an  inch.  The  mucous 
membrane2  of  the  clitoris,  especially  that  which  covers  the  glans,  is 
very  rich  in  nervous  papillae,  containing  corpuscles  of  Krause  and 
Pacini. 

In  the  first  three  months  of  intra-uterine  life  the  clitoris  is  relatively 
so  large  that  a  mistake  in  the  sex  of  the  product  of  abortion  is  liable  to 
be  made.  So,  too,  hypertrophy  of  this  organ  in  children  and  in  adults 
explains  some  of  the  cases  of  supposed  hermaphrodism. 

The  clitoris  is  the  analogue  of  the  penis  ;  it  is  an  organ  concerned 
in  copulation,  but  to  regard  it  as  the  chief  or  exclusive  seat  of  sexual 
passion  is  an  error.3  It  has  been  asserted  that  the  clitoris  is  hyper- 
trophied by  masturbation  ;  but  this  is  no  more  true  than  that  males 
have  hypertrophy  of  the  penis  from  the  same  cause.4 

THE  VESTIBULE.  The  nyrnphse,  diverging  as  they  descend  from 
the  clitoris,  make  the  sides  of  a  triangle,  the  base  being  the  intervening 


1  Three  derivations  of  clitoris  have  been  given  :  First,  from  K/^eiu  to  shut  up,  because  con- 
cealed by  the  labia  ;  second,  from  /c/l«rWw,  to  lock,  the  vulva  being  closed  and  the  clitoris  sup- 
posed to  point  to  the  keyhole  ;  and  third,  from  K.7-i/-up,  Doric,  nAfirop,  one  who  invites,  here  the 
clitoris  qux  invitat  ad  coltum. 

-  De  Sinety. 

3  The  anatomist  Colombus  called  this  organ  veneris  amor  et  dulcedo.  A  recent  obstetric  author, 
Saboia,  seems  to  adopt  the  same  view,  for  he  says  that  the  clitoris  is  the  chief  organ  of  voluptuous 
feeling  in  the  female. 

<  Winckel. 


THE  FEMALE  SEXUAL  ORGANS.  49 

margin  of  the  vagina,  and  to  the  space  thus  included  the  name  of  vesti- 
bule is  given  ;  the  triangle  is  equilateral,  each  .side  measuring  about  one 
inch,  2.5  centimetres.  Just  above  the  middle  of  the  base  of  the  triangle 
the  orifice  of  the  urethra,  meatus  urinarius,  is  found ;  this  orifice  is  cir- 
cular and  often  presents  an  irregular,  elevated,  and  rather  firm  margin, 
so  that  it  may  be  recognized  by  the  finger  gently  pressing  upon  it; 
there  may  also  often  be  felt  at  the  lower  margin  of  the  orifice  a  projec- 
tion known  as  the  urethro-vaginal  tubercle. 

INTRODUCTION  OF  THE  CATHETER.  A  flexible  rubber  catheter  is 
usually  preferred  when  artificial  evacuation  of  the  bladder  is  necessary ; 
the  beak  of  the  instrument  and  the  forefinger  having  been  oiled,  the 
latter  is  introduced  into  the  vagina  and  its  palmar  surface  placed  upon 
the  lower  part  of  the  anterior  vaginal  wall  in  the  median  line ;  the 
cathether  is  now  passed  along  the  upper  surface  of  the  finger  until  it 
touches  the  margin  of  the  vagina,  and  then  a  slight  elevation  of  the 
point  of  the  instrument  brings  it  in  the  mouth  of  the  urethra.  Another 
method  of  introducing  the  catheter,  though  in  some  cases  very  objec- 
tionable because  of  the  great  sensitiveness  of  the  clitoris,  is  to  pass  the 
finger  from  above,  separating  the  nymphse,  down  the  middle  line  of  the 
vestibule  about  four-fifths  of  an  inch,  when  the  surface,  hitherto  smooth, 
becomes  irregular,  uneven,  and  the  orifice  of  the  urethra  being  felt,  the 
catheter  is  readily  passed. 

When  coition  occurs  in  girls  before  the  development  of  the  sexual 
organs,  it  is  not  uncommon  to  find  the  urinary  meatus  hidden  under  the 
pubic  arch,  a  partial  inversion  of  the  vulva  having  been  produced;  and 
a  similar  displacement  of  the  meatus  is  sometimes  found  in  posterior 
displacement  of  the  gravid  uterus.  On  the  other  hand,  a  reverse  dis- 
placement of  the  meatus  may  be  observed  after  a  severe  labor  and  con- 
sequent great  swelling  of  the  parts — the  meatus  is  then  further  from  the 
vaginal  entrance  and  lies  somewhat  obliquely  with  reference  to  the 
normal  position  of  the  plane  of  the  vestibule :  very  rarely,  however,  is 
exposure  necessary  for  catheterization. 

HYMEN/  AND  CARUNCUL,^2  MYRTIFORMES.  According  to  Budin,3 
the  hymen  as  a  distinct  membrane  does  not  exist ;  it  is  simply  the  lower 
end  of  the  vagina,  perforated  like  the  extremity  of  the  finger  of  a  glove ; 
or,  it  may  be  compared  to  the  partially  inverted  and  narrow  fringed 
margin  of  a  pantalette.  But  this  view  has  not  met  general  acceptance, 
and  the  following  is  probably  the  true  explanation  of  the  origin  of  the 

1  From  vp/v,  a  membrane. 

2  Not  given  this  name  from  their  resemblance  to  myrtle-berries,  but  from  their  resemblance  to 
myrtle-leaves,  as  stated  by  Winslow. 

3  Budin's  statement  is  upheld  by  Dr.  Gustave  Imbert  in  a  monograph  upon  the  development  of 
the  uterus  and  vagina.    Dr.  Imbert  says,  referring  to  the  hymen :  In  view  of  its  structure  some 
admit  that  this  membrane  is  formed  by  a  fold  of  the  mucous  membrane  of  the  vagina ;  others,  that 
it  results  from  the  vulval  and  vaginal  mucous  membranes  being  placed  against  each  other.    Prop- 
erly speaking,  the  hymen  is  nothing  but  the  anterior  extremity  of  the  vagina  covered  externally 
by  the  vulval  mucous  membrane  ;  this  is  proved  not  only  by  histolqgical  examination,  but  by  a 
dissection  which  shows  the  prolongation  of  the  columns  and  the  ridges  of  the  vaginal  mucous 
membrane  upon  its  internal  face  and  up  to  the  orifice  of  the  hymen.    When  the  vagina  is  isolated 
from  connected  parts  it  appears  as  a  canal  ending  in  front  by  a  perforated  hemispherical  part. 
Developpement  de  1'Uterus  et  du  Vagina,  Paris,  1883.    Dohrn  states  (Zeitschrift  fur  Geburtshiilfe 
und  Gynakologie,  1885)  that  the  development  of  the  hymen  is  closely  connected  with  the  increase 
in  the  length  of  the  vagina,  and  that  in  proportion  to  this  increase  an  excess  of  tissue  is  produced, 
which  takes  the  form  of  a  fold  projecting  over  the  vaginal  entrance ;  as  the  posterior  wall  of  the 
vagina  exceeds  in  growth  the  anterior,  the  first  beginning  of  the  hymen  is  seen  upon  the  former, 
and  here  it  has  a  broader  base,  while  the  hymenal  opening  is  nearer  the  anterior  vaginal  wall. 


50  PHYSIOLOGY  OF  PREGNANCY. 

hymen  :l  About  the  nineteenth  week  of  intra-uterine  life  the  first  trace 
of  the  hymen  appears  as  a  slight  projection  on  the  posterior  wall  of  the 
vagina,  just  above  the  point  where  the  vagina  unites  with  the  uro- 
genital  sinus.  A  smaller  projection  then  appears  upon  the  anterior 
vaginal  wall,  but  somewhat  higher.  The  two  soon  unite  at  the  sides. 
Papilla3  are  found  upon  the  internal  surface  of  the  hymen,  but  its  ex- 
ternal surface  is  smooth,  like  that  of  the  vestibule.  It  is  composed  of 
fibrillated  stroma  of  connective  tissue,  has  arteries  and  veins,  and  is  rich 
in  elastic  fibres ;  muscular  tissue  is  found  in  it,  and  the  presence  of 
nerves  is  proved  by  its  exquisite  sensitiveness  in  some  cases.  Winckel 
thinks  its  purpose  is  to  prevent  the  entrance  of  amnial  fluid  into  the 
genital  canal  during  labor-pains.  In  some  cases  the  hymen  presents  a 
crescent  form,  and  apparently  occupies  only  the  lower  portion  of  the 
vaginal  entrance ;  again,  it  may  be  a  membrane  with  a  single  central 
opening,  or  with  several  small  perforations  like  a  colander,  or,  finally, 
it  may  completely  close  the  vagina,  rendering  discharge  of  the  menstrual 
fluid  or  entrance  of  the  penis  impossible.  Rupture  of  the  hymen  usually 
occurs  at  the  first  sexual  intercourse,  but  it  may  result  from  other  causes, 
thought  it  is  impossible,  as  some  have  alleged,  from  any  change  of  posi- 
tion of  the  lower  limbs.  If  the  vagina  be  large  and  greatly  relaxed,  the 
hymen  may  retain  its  integrity  after  repeated  congress.  In  rare  in- 
stances it  has  proved  an  obstacle  to  childbirth,  and  its  incision  been 
necessary.  Only  a  few  drops  of  blood  usually  follow  its  rupture,  but 
in  some  cases  a  severe  hemorrhage  occurs. 

The  myrtiform  caruncles,  or  hymenal  tubercles,  as  Dubois  termed 
them,  are  small  fleshy  tubercles,  two  to  five  in  number,  found  after  com- 
plete rupture  of  the  hymen  at  the  part  of  the  vagina  formerly  occupied 
by  its  circumference.  They  are  not  seen,  according  to  Schroder  and 
Budin,  until  after  labor,  which  converts  the  vagina  and  vulva  into  a 
common  passage.  They  differ  in  size  in  different  subjects,  being  so 
small  in  some  as  to  be  hardly  visible,  while  in  others  they  are  relatively 
quite  large. 

VULVAL  CANAL  AND  NAVICULAR  FOSSA.  The  vulval  orifice  is 
usually  closed  by  approximation  of  the  labia  majora,  but  upon  sepa- 
rating them  a  space  is  seen,  shallow  above  at  the  vestibule,  much  deeper 
below  at  the  posterior  commissure,  having  somewhat  the  shape  of  a 
funnel,  the  smallest  part  being  at  the  vaginal  entrance  ;  this  is  the  vul- 
val canal. 

So,  too,  upon  separating  the  labia  there  is  distinctly  seen  in  the  nulli- 
para,  not,  however,  so  apparent  in  the  parous,  a  depressed  surface  ex- 
tending from  the  fourchette  to  the  hymen,  or  to  the  myrtiform  carun- 
cles ;  this  depression  has  been  given,  from  a  fancied  resemblance  to  a 
boat,  the  uame  of  navicular  fossa. 

VULVAL  GLANDS.  The  glandular  supply  of  the  mons  and  of  the 
greater  and  less  lips  has  been  stated ;  the  richness  of  the  nymphse  in 
sebaceous  glands  not  only  keeps  these  parts  soft  and  pliable,  but  also 
guards  them  against  injury  from  the  contact  of  urinary  and  utero- 
vaginal  discharges.  But  in  addition  to  the  glands  previously  mentioned 

i  Winckel. 


THE  FEMALE  SEXUAL  ORGANS.  51 

there  are  other  vulval  glands  to  be  noticed.  Huguier  has  described 
four  groups  of  muciparous  follicles — though  discredited  by  Sappey — 
vestibular,  urethral,  latero-urethral,  and  latero- vaginal.  Skene,1  in  1880, 
gave  a  description  of  two  glands  situated  just  within  the  meatus  upon 
each  side,  near  the  floor  of  the  urethra ;  these  glands  are  from  three- 
eighths  to  three-quarters  of  an  inch  in  length. 

The  vulvo-vaginal  glands — also  known  as  the  glands  of  Bartholin 
and  of  Duverney — are  in  the  female  the  analogues  of  Cowper's  glands 
in  the  male.  They  are  situated  at  the  sides  and  posterior  part  of  the 
vaginal  entrance,  about  two-fifths  of  an  inch,  or  one  centimetre,  above 
the  anterior  face  of  the  hymen  or  of  the  hymenal  tubercles,  and  just 
below  the  bulb  on  each  side. 

They  vary  in  size,  in  some  cases  as  small  as  a  pea,  in  others  as  large  as 
a  hazelnut;  their  usual  form  is  that  of  a  flattened  ovoid.  They  are  com- 
posed of  lobes,  lobules,  and  acini ;  from  the  acini  canaliculi  pass,  which, 
lessening  in  number  and  increasing  in  size  in  their  further  progress, 
finally  open  in  a  single  efferent  duct.  A  covering  of  fibrous  and  con- 
nective tissue,  sending  prolongations  between  the  lobes  and  lobules, 
invests  each  gland.  These  glands  are  lined  with  a  cup-shaped  epithe- 
lium closely  resembling  that  of  the  glands  of  the  cervical  canal,  and 
hence  the  similarity  of  the  secretion,  which  is  a  tenacious,  usually  color- 
less fluid,  that  lubricates  the  vulval  orifice  and  thus  faciltiates  coition. 
In  some  females  the  secretion  is  discharged  in  a  jet,  and  this  fact  led  to 
the  long  since  rejected  belief  that  woman  as  well  as  man  furnished  semen 
in  coition,  and  the  new  being  was  the  product  of  the  united  discharges. 

BLOODVESSELS,  LYMPHATICS,  AND  NERVES  OF  THE  EXTERNAL 
SEXUAL  ORGANS.  The  arterial  supply  of  these  organs  is  by  branches 
from  the  external  and  internal  pudics  and  the  epigastrics.  The  return 
of  blood  is  chiefly  through  the  external  pudic  veins.  The  lymphatic 
vessels  communicate  with  inguinal  ganglia.2  The  nerves  are  from  the 
external  pudic  nerve  and  from  the  geuito-crural  and  abdominal  branches 
of  the  lumbar  plexus. 

THE  INTERNAL  ORGANS  OF  GENERATION.  The  internal  organs 
of  generation  are  the  vagina,  the  uterus,  the  ovaries,  and  the  oviducts. 

THE  VAGINA.3  The  vagina  is  usually  described  as  a  musculo- 
membranous  canal  extending  from  the  vulva  to  the  uterus.  From  its 
continuity  with  the  vulva  it  is  an  organ  of  copulation ;  and  from  its 
connection  with  the  uterus  it  is  an  excretory  canal  for  uterine  secretions 
and  the  monthly  flow,  and  through  it  as  part  of  the  birth-canal  the 
foetus  with  its  appendages  passes.  It  is  placed  behind  the  urethra  and 
the  bladder  and  in  front  of  the  rectum ;  it  passes  from  the  uterus 
obliquely  from  above  downward  and  from  behind  forward.  It  forms 
an  obtuse  angle  with  the  uterus  when  the  bladder  is  full,  but  if  the 
latter  be  empty,  a  right-angle.  Its  posterior  wall  is  about  four  inches, 
or  ten  centimetres,  in  length,  while  its  anterior  wall  is  a  little  more  than 

1  American  Journal  of  Obstetrics. 

2  "  It  ought  not  to  be  forgotten  that  the  superficial  lymphatics  of  the  groin  have  a  double  com- 
munication with  those  of  the  iliac  fossa  by  vessels  which  pass  through  the  cribriform  fascia  to 
reach  the  deep  lymphatics,  and  by  the  ganglion  which  generally  occupies  the  orifice  of  the  inguino- 
crural  canal."— Siredey. 

3  Vagina  means  a  sheath.    The  old  anatomists  called  the  vagina  the  cervix,  and  the  ostiuin 
uteri ;  even  Dionis  and  Mauriceau  described  it  as  the  neck  of  the  womb. 


52  PHYSIOLOGY  OF  PREGNANCY. 

three  inches,  or  eight  centimetres.  Ribemont-Dessaignes  and  Lepage 
Precis  d' Obstetrique,  1893,  state  the  length  of  the  vagina  anteriorly  as 
2.26-2.67^  inches,  and  posteriorly  8.17  inches.  But  these  are  only 
approximate  measurements,  for  the  length  of  the  vaginal  canal  varies 
in  different  subjects  and  at  different  ages ;  it  has  been  stated  that  in 
the  n egress  this  canal  is  longer  than  in  the  white  woman ;  it  is  rela- 
tively longer  in  the  newborn  than  in  the  adult,1  the  proportion  to  the 
length  of  the  body  being  in  the  former  one  to  nine,  while  in  the  latter 
it  is  one  to  fifteen. 

When  the  organ  is  at  rest  the  anterior  rests  upon  the  posterior  wall, 
the  two  being  in  immediate  contact,  so  that  a  section  would  represent  a 
transverse  slit,  rather  than  a  cavity.  Nevertheless  it  is  usual  to  refer 
to  the  vaginal  diameters.  The  calibre  of  the  vagina  is  least  at  the 
vulva  and  gradually  increases  as  the  organ  ascends  to  the  uterus,  so  that 
were  the  vaginal  walls  held  apart  it  would  represent  not  a  hollow 
cylinder,  but  a  hollow  truncated  cone,  the  base  of  the  cone  being  above ; 
the  mean  antero-posterior  and  transverse  measurements  are  in  the  uulli- 
parous  from  rather  more  than  an  inch  to  an  inch  and  a  half,  three  to 
four  centimetres ;  in  the  parous  two  inches  and  a  quarter  to  two  inches 
and  a  half,  or  about  six  to  seven  centimetres.  But  in  labor  the  vagina 
is  so  greatly  stretched  that  these  diameters  become  nearly  equal  to  those 
of  the  pelvis. 

The  anterior  wall  of  the  vagina  is  in  relation  with  the  urethra,  the 
bas-fond  of  the  bladder,  and  with  the  ureters.  The  union  between 
the  vagina  and  the  urethra,  especially  at  the  inferior  portion  of  the 
latter,  is  very  intimate,  and  interchange  of  fibres  takes  place ;  that 
between  the  vagina  and  bladder  is  of  looser  connective  tissue,  in  which 
numerous  blood-  and  lymph-vessels  are  found.  Posteriorly  the  vagiua 
is  in  relation  with  the  peritoneum2  nearly  four-fifths  of  an  inch,  or  some- 
what less  than  two  centimetres,  the  descent  of  the  peritoneum  from  the 
posterior  wall  of  the  uterus  to  be  reflected  over  the  anterior  wall  of  the 
rectum  forming  a  pouch  variously  known  as  Douglas's,  the  recto-uterine 
cul-de-sac,  and  retro-uterine  cul-de-sac.  The  subperitoueal  tissue  is  here 
quite  thin.  Below  the  cul  de-sac  the  vagina  is  in  relation  with  the  rec- 
tum, but  the  connective  tissue  uniting  the  two  above  is  quite  loose,  so 
that  intra-peritoueal  effusions  may  cause  great  descent  of  the  peritoneal 
pouch.  From  the  curving  forward  of  the  vagina  below,  and  curving 
backward  of  the  rectum,  these  organs  are  there  placed  further  apart,  so 
that  a  section  of  the  recto- vaginal  wall,  made  antero-posteriorly,  would 
have  the  form  of  a  triangle,  its  base  extending  from  the  anus  to  the 
vulva  and  its  apex  being  immediately  below  the  cul-de-sac.  Laterally 
the  vagina  is  in  relation  with  the  vaginal  bulbs  and  sphincter,  connec- 
tive and  fatty  tissue,  the  anal  levator,  the  lowest  portion  of  the  broad 
ligaments,  and  the  pelvic  aponeurosis. 

At  its  upper  end  the  vagina  is  continuous  with  the  uterus  by  means 
of  muscular  fibres  common  to  the  two  organ  and  by  mucous  membrane 
passing  from  one  to  the  other.  This  connection  is  made  at  the  junc- 


1  Huscnke. 

2  According  to  Bayer  (Morphologie  der  Gebarinutter),  the  peritoneum  may  pass  from  the  uterus 
at  the  same  height  upon  the  posterior  as  upon  the  anterior  wall,  and  iu  such  case,  of  course,  the 


THE  FEMALE  SEXUAL  ORGANS. 


tion  of  the  lower  with  the  middle  third  of  the  uterine  neck,  a  little 
higher  behind  than  in  front,  and  the  neck  is  thus  divided  in  two  parts, 
one  iutra-vaginal  and  the  other  supra- vaginal ;  the  former  is  by  some 
called  the  portio  vaginalis,  or  vaginal  portion. 


FIG.  23.1 


SITUATION  AND  RELATIONS  OF  THE  UTERUS. 

1.  Body  of  the  uterus.  2.  Cavity.  3.  Neck.  4.  Cavity  of  the  neck.  5.  Intra-vaginal  part  ot 
the  neck.  6.  Vagina.  7.  Vaginal  orifice.  8.  Bladder.  9.  Urethra.  10.  Vesico-vaginal  wall. 
11.  Rectum.  12.  Rectal  cavity.  13.  Anus.  14.  Recto- vaginal  wall.  15.  Perineum.  16.  Vesico- 
uterine  cul-de-sac.  17.  Utero-rectal  cul-de-sac.  18.  Pubic  symphysis.  19.  Small  lip.  20.  Great  lip. 

In  consequence  of  the  vaginal  walls  arching  over  to  unite  with  the 
uterus  a  dome  or  vault,  sometimes  called  the  vaginal  fornix,  is  formed ; 


1  In  taking  this  plate  from  Sappey  some  slight  changes  have  been  made  so  as  to  represent  the 
vaginal  walls  nearer  together.  Nor  does  the  illustration  accurately  represent  the  normal  form  and 
position  of  the  uterus  ;  these  are  correctly  shown  in  Figs.  41  and  42,  from  Schultze,  the  bladder 
being  empty.  There  is  a  physiological  anteflexion  of  the  organ,  not  represented  in  the  illustration ; 
moreover,  according  to  Hart  and  Barbour,  the  anterior  surface  of  the  uterus  rests  upon  the  bladder ; 
if  the  latter  be  full,  the  uterus  is  retroposed. 

Van  der  Warker,  as  one  of  the  conclusions  of  his  study  upon  the  Normal  Position  and  Movements 
of  the  Unimpregnated  Uterus,  American  Journal  of  Obstetrics,  vol.  xi.,  correctly  states  that  the 
anatomical  idea  of  coincidence  between  the  uterine  and  the  pelvic  axes,  maintained  with  more  or 
less  relative  exactness,  is  obsolete. 


54  PHYSIOLOGY  OF  PREGNANCY. 

this  vault  is  divided  into  two  lateral  culs-de-sac,  distinguished  as  right 
and  left,  and  one  anterior  and  one  posterior ;  the  last  is  the  deepest. 

The  vaginal  is  continuous  with  the  vulval  canal  below :  as  the  union 
between  the  two  is  made  at  the  narrowest  part  of  each,  a  strait  is  formed 
which  is  in  some  cases  the  cause  of  serious  delay  in  childbirth.  The 
anterior  and  posterior  walls  of  the  vagina  present  transverse  elevations, 
those  on  the  former  being  more  prominent  than  those  on  the  latter. 
These  elevations,  sometimes  improperly  called  rugce,1  are  more  distinct 
at  the  entrance  of  the  vagina,  and  gradually  lessen  until  they  disappear 
a  little  above  the  middle  of  the  canal ;  the  so-called  rugse  on  the  pos- 
terior wall  in  many  cases  ascend  higher  than  those  on  the  anterior  wall. 
Labor  temporarily  effaces  them,  and  after  it,  though  gradually  reform- 
ing, they  are  never  so  distinct  as  in  the  nulliparous.  Two  longitudinal 
elevations  are  formed  at  the  junction  of  the  transverse  ridges  in  the 
median  line,  one  on  the  anterior,  the  other  on  the  posterior  vaginal 
wall,  that  on  the  former  being  the  more  prominent,  which  are  called 
the  vaginal  columns,  and  also  the  columnce  rugarum.  The  longitudinal 
and  transverse  elevations  form  what  is  called  the  lyre.  Neither  the 
columns  nor  the  ruga?  are  directly  opposite,  and  thus  more  complete 
apposition  of  the  walls  is  secured.  At  the  lowest  portion  of  the  anterior 
column  a  projection  is  observed,  tuberculum  vagince;  this  is  important 
as  a  guide  to  the  urethral  opening,  which  is  just  above  the  tubercle. 

FIG.  24. 


SECTION  OP  THE  Mucous  MEMBRANE  OP  THE  VAGINA,  SHOWING  CYLINDRICAL  CELLS. 

The  walls  of  the  vagina  are  from  one-eighth  to  one-sixth  of  an  inch, 
three  to  four  millimetres,  in  thickness.  They  are  composed  of  three 
coats  or  layers,  the  external  fibrous,  the  middle  muscular,  which  makes 
two-thirds  of  the  thickness  of  the  wall,  and  the  internal  mucous.  The 
first  is  formed  of  connective  tissue  and  elastic  fibres ;  it  contains  large 
bloodvessel  branches  and  nerve-tracts.  It  is  in  relation  externally  with 
the  organs  which  encircle  the  vagina,  and  internally  with  the  middle 
coat.  The  arrangement  of  the  muscular  fibres  composing  the  middle 
coat  is  given  differently  by  authors.  According  to  Henle,  the  external 
layer  is  circular  and  the  internal  longitudinal ;  while  Luschka  gives 
a  reverse  disposition  of  these  fibres,  the  longitudinal  being  external, 
the  internal  circular,  and  between  the  two  oblique  fibres  are  found. 
Tarnier  describes  the  muscular  fibres  as  inserted  below  in  the  ischio- 
pubic  rami  and  continued  above  with  the  middle  of  the  three  muscular 
layers  of  the  uterus ;  some  extend  into  the  utero-sacral  ligaments,  and 

1  "  These  projections  have  been  regarded  as  simply  folds  of  the  mucous  membrane  which  are 
effaced  in  coition,  and  especially  in  labor.  But  they  are  not  at  all  similar  to  folds.  They  are  pro- 
longations, elevated  above  the  walls  of  the  canal  ....  and  do  not  contribute  to  enlargement 
of  the  vaginal  cavity,  but  to  coition."— Sappey. 


THE  FEMALE  SEXUAL  ORGANS. 


55 


others  cross  each  other  in  all  directions,  leaving  spaces  occupied  by 
venous  enlargements. 

The  mucous  membrane  is  pale  red  ordinarily,  but  during  menstrua- 
tion, and  especially  in  pregnancy,  becomes  violet-colored.     Very  numer- 


FIG.  25. 


K 


ARTERIES  AND  VEINS  OF  VAGINA  AND  UTERUS.    (SAVAGE.) 

B.  Bladder  cut  at  urachus  and  turned  forward.    R.  Rectum.    L.  Round  ligament.     Is.  Uterus. 

0.  Ovary.     V.  Vagina.     S.  Sacro-iliac  articulation.     K.  Kidney.     T.  Fallopian  tube.    P.  Pubic 
symphysis.    a.  Pyriformis  muscles,    b.  Gluteal  muscles,    c.  Ischio-coccygeus  muscle,     d.  Internal 
obturator  muscle,     e,  e.    Psoas  muscle.    /.  Linea  alba,      g,  g.    Ureters,      h.  Obturator  nerve. 

1.  Internal  inguinal  ring.    1.  Abdominal  aorta.    2.  Inferior  mesenteric  artery.    3,  3.  Common  iliac 
arteries.    4.  External  iliac  artery.     5.  Vena  cara.     6.  Renal  veins.     7,  7.  Common  iliac  veins. 
8.  External  iliac  vein.    9.  Internal  iliac  artery.    10.  Gluteal.     11.  Ileo-lumbar.    12.  Sciatic.    13. 
Pudic.    14.  Obturator.     15.  Epigastric  vein.     17.  Uterine  veins.    18.  Vagino-vesical  venous  rete. 
19.  Spermatic  veins.    20.  Bulb  of  ovary.    21.  Vein  to  round  ligament.    22.  Fallopian  veins. 


56  PHYSIOLOGY  OF  PREGNANCY. 

ous  microscopic  papillae  supplied  with  bloodvessels  are  found  in  the 
lower  part  of  the  vagina,  but  are  scanty  in  the  upper  part.  While  it  is 
commonly  stated  that  the  vaginal  mucous  membrane  is  covered  with 
pavement-epithelium,  according  to  v.  Preuschen  the  lowest  layer  shows 
cylindrical  epithelium.  By  Sappey  and  most  other  anatomists  the 
presence  of  glands  in  the  mucous  membrane  of  the  vagina  is  denied, 
but  the  investigations  of  v.  Preuschen,  confirmed  by  those  of  Ruge, 
seem  to  prove  their  existence.  They  are  not  abundant,  and  are  similar 
in  form  to  the  sebaceous  follicles  of  the  vulva  ;  in  the  superficial  portion 
of  the  sinuous  ducts  pavement-epithelium  is  present,  but  deeper,  as  in 
a  section  of  the  mucous  membrane  of  the  vagina  cylindrical  epithelium 
is  found,  while  in  the  remaining  part  of  the  gland  both  pavement  and 
ciliated  cylindrical  epithelium  occur. 

VESSELS  AND  NERVES  OF  THE  VAGINA.  The  arterial  supply  is 
chiefly  through  the  vaginal — derived  from  the  anterior  branch  of  the 
internal  iliac — and  from  branches  from  the  uterine,  inferior  vesical,  and 
internal  pudic.  The  veins,  which  are  many  and  large,  empty  into  the 
venous  plexuses,  situated  at  the  sides  of  the  vagina.  The  lymphatics 
of  the  lower  fourth  of  the  vagina,  uniting  with  those  of  the  vulva,  com- 
municate with  the  ganglia  of  the  groin,  while  those  of  the  remaining 
three-fourths  enter  the  lateral  pelvic  ganglia.  The  nerves  are  derived 
from  the  hypogastric  plexus. 

FIG.  26. 


BULBS  OF  THE  VAGINA. 
A .  Clitoris.    B.  Bulbs.    C,  D   Right  and  left  halves  of  the  vaginal  constrictor. 

THE  BULBS  OF  THE  VAGINA.  These  are  two  erectile  organs 
placed  upon  the  anterior  and  lateral  parts  of  the  vagina  ;  they  are  below 
and  within  the  pubic  rami,  their  internal  concave  surface  embracing 
the  vaginal  orifice,  their  external  convex  surface  being  covered  by  the 
bulbo-caveruosus  muscle.  Above,  the  bulbs  are  united  by  veins  and 
muscular  fibres;  the  anterior  borders  have  veins  communicating  with 
the  veins  of  the  nympha?  and  of  the  clitoris.  A  bulb  has  been  com- 
pared by  Kobelt  to  a  leech  gorged  with  blood.  According  to  Savage, 
a  single  bulb  when  filled  with  blood  is  an  inch  and  a  half  long  and 


THE  FEMALE  SEXUAL  ORGANS.  57 

half  an  inch  thick;  while  the  measurements  given  by  Sappey,  and  by 
Taruier  and  Chantreuil,  and  by  Charpentier  are  :  length,  one  inch  and 
one-tenth — thirty-five  millimetres;  breadth,  half  an  inch — fifteen  milli- 
metres ;  thickness,  three-  to  four-tenths  of  an  inch,  or  ten  to  twelve 
millimetres. 

FIG.  27. 


INTERNAL  GENITAL  ORGANS. 

C.  Anterior  part  of  the  neck  of  the  uterus.  L.  Broad  ligament  of  left  side.  L'.  Part  of  broad 
ligament  of  right  side.  M.  Ligament  of  right  ovary.  0.  Left  ovary.  0'.  Right  ovary.  P.  Pavilion 
of  left  oviduct.  P'.  Pavilion  of  right  oviduct.  R.  Round  ligament  of  left  side.  R'.  Round  liga" 
ment  of  right  side.  T.  Left  oviduct  T'.  Right  oviduct.  U.  Body  of  uterus  seen  from  anterior 
face.  V.  Vagina  opened  from  above  below.  V.  Middle  column  of  posterior  vaginal  wall. 


THE  UTERUS.  Womb,1  matrix,  from  the  Latin  mater,  Greek  ^r^p, 
,  German,  Mutter  and  Gebarmutter.  The  Greek  P-^p,  the  Latin 
mater,  the  Sanscrit  main,  and  German  Mutter,  show  a  striking  analogy 
with  the  word  "  rant,"  which,  according  to  the  famous  Egyptologist, 
Professor  Ebers,  was  used  in  ancient  Egypt  as  the  name  of  the  womb. 

1  The  word  womb  was  not  at  first  employed  to  designate  this  organ  of  the  female,  but  was  used 
for  the  belly  or  abdomen.  Thus,  in  Wycliffe's  translation  of  the  Bible,  1380,  in  the  parable  of  the 
Prodigal  Son,  the  translator  states  the  fact  that  the  prodigal  would  fain  have  filled  his  belly  with 
the  husks  which  the  swine  did  eat,  as  he  would  have  filled  "  his  wombe,"  etc.  In  the  same  cen- 
tury Chaucer  wrote  his  famous  poems;  and  in  the  Squire's  Tale,  Canterbury  Tales,  the  following 
passage  is  found : 

"  He  kissed  her,  and  clipped  her  full  oft, 
And  on  her  womb  he  stroked  her  full  soft,"  etc. 

The  word  "  clipped  "  is  embraced.  These  quotations  show  how  far  astray  those  lexicographers 
are  who  have  derived  the  word  woman  from  womb-man. 


58  PHYSIOLOGY  OF  PREGNANCY. 

The  uterus  is  the  organ  in  which  the  impregnated  ovule  is  developed 
and  by  which  the  foetus  and  its  appendages  are  expelled  from  the 
mother's  body  when  the  development  is  complete ;  it  is,  therefore,  the 
organ  of  gestation  and  the  organ  of  parturition.  It  is  situated  in  the 
pelvic  cavity  with  its  fundus  usually  just  below  the  plane  of  the  inlet; 
it  is  behind  the  bladder  and  in  front  of  the  rectum,  while  at  its  sides 
are  the  broad  ligaments  which  pass  from  it  to  be  attached  to  the  lateral 
walls  of  the  pelvis.  The  uterus  has  been  by  some  described  as  pear- 
shaped,  and  by  others  as  resembling  a  gourd  ;  that  portion  which  lies 
above  the  reflection  of  the  peritoneum  over  the  posterior  wall  of  the 
bladder  presents  somewhat  the  form  of  an  inverted  truncated  cone, 
while  that  which  is  below  is  cylindrical.  A  slight  depression  or  con- 
striction upon  its  external  surface,  more  distinct  in  the  virgin  than  in 
the  parous  uterus — more  distinct,  too,  anteriorly  than  posteriorly — 
known  as  the  isthmus,  marks  the  separation  just  mentioned;  all  that 
part  of  the  organ  above  the  isthmus  is  called  the  body,  or  corpus, 
while  that  below  is  the  neck,  or  cervix.  If  a  line  be  drawn  from  the 
uterine  end  of  one  oviduct  to  that  of  the  other,  the  portion  of  the  body 
or  corpus  above  this  line  is  known  as  the  fundus.  In  infancy  and  in 
childhood  the  uterus  is  small,  but  it  is  remarkably  developed  at  puberty ; 
it  is  atrophied  after  the  menopause ;  it  is  temporarily  increased  in  size, 
one-half  or  more,  during  menstruation ;  it  is  larger  in  the  parous  than 
in  the  nulliparous,  larger,  too,  in  the  married  than  in  the  virgin.  The 
virgin  uterus  is  about  two  inches  and  a  half,  or  seven  centimetres,  in 
length,  its  greatest  lateral  measurement  is  about  one  inch  and  a  half,  or 
four  centimetres,  and  its  antero-posterior  measurement  is  nearly  one 
inch,  or  two  and  five-tenths  centimetres. 

Its  weight  in  the  nullipara  is  from  eight  to  ten  drachms,  or  thirty- 
two  to  forty-two  grammes.  The  weight  of  the  parous  uterus  is  from 
one-fourth  to  one-third  greater. 

The  anterior  face  of  the  uterus  is  triangular,  somewhat  convex  ;  the 
posterior  face  is  also  triangular,  and  its  convexity  is  quite  marked ; 
its  superior  border  is  convex  from  before  back,  nearly  straight  from  side 
to  side  in  the  nulliparous,  but  convex  in  the  parous  uterus;  the  sides 
curve  somewhat  inward  from  above  down,  and  are  convex  from  before 
back.  The  angles  of  the  uterus  mark  the  union  of  the  superior  border 
with  the  lateral  borders ;  they  also  correspond  with  the  attachment  of  the 
oviducts.  The  lower  end  of  the  body  of  the  uterus  is  continuous  with 
the  upper  end  of  the  neck,  the  isthmus  marking  the  place  at  which  one 
passes  into  the  other. 

The  relative  proportions  of  the  body  and  the  neck  differ  in  the  child 
from  those  in  the  adult ;  so,  too,  this  relation  differs  in  the  nulliparous 
and  in  the  parous.  In  the  child  at  birth,  and  for  the  first  following 
years,  the  neck  is  three-fifths  of  the  entire  organ,  but  in  the  nulliparous 
only  a  little  less  than  half;  in  the  parous  the  body  is  three-fifths  to  two- 
thirds  the  entire  uterus. 

The  cervix  in  the  virgin  has  nearly  the  form  of  a  cylinder ;  it  is, 
however,  somewhat  enlarged  in  the  middle  like  a  barrel,  and  flattened 
from  before  back,  so  that  the  antero-posterior  diameter  is  a  little  less 
than  the  transverse.  It  is  commonly  stated  that  the  upper  third  of  the 


THE  FEMALE  SEXUAL  ORGANS.  59 

anterior  surface  of  the  cervix  is  covered  by  peritoneum,  while  the  middle 
third  is  attached  to  the  bladder;  the  investigations  of  Bayer,  however, 
show  that  the  peritoneum  is  usually  reflected  from  the  anterior  wall  of 
the  uterus  at  a  point  corresponding  with  the  internal  os  uteri,  and, 
therefore,  this  membrane  does  not  cover  any  portion  of  the  cervix 
anteriorly.  The  vaginal  portion  of  the  neck — its  lower  third — in  the 
virgin  is  smooth  ;  as  it  descends  it  lessens  in  size  and  is  rounded  at  its 
lowest  part ;  in  the  middle  of  this  rounded  part  an  opening,  the  os 
uteri,  is  found  having  usually  the  form  of  a  short  transverse  slit,  which 
becomes  circular  when  mucus  or  blood  is  expelled ;  to  the  finger  it  feels 
like  a  simple  depression.  In  the  normal  form  of  the  virgin  cervix  any 
division  of  the  tissue  surrounding  the  mouth  of  the  womb  into  an 
anterior  and  a  posterior  lip  is  purely  arbitrary,  in  most  cases  nothing 
can  be  seen  or  felt  but  a  uniform  unbroken  border;  the  distinction  of 
anterior  and  posterior  lip  is  almost  invariably  the  result  of  a  traumatism 
in  labor,  and  the  traumatism  is  usually  physiological,  not  pathological. 
In  quite  rare  cases,  however,  labor  may  occur  without  any  tears  of  the 
os,  so  that  the  latter  retains  its  virgin  character.  So,  too,  in  some  cases 
in  which  the  fashionable  operation  for  laceration  of  the  cervix  has  been 
done,  the  skill  of  the  operator  may  have  perfectly  restored  the  original 
form  of  the  os.  Hence,  an  obstetrician,  finding  an  os  with  the  virgin 
form,  in  consequence  of  no  tear  having  occurred  at  childbirth,  or  be- 
cause perfect  restoration  has  been  made  by  an  operation,  may  erroneously 
conclude  that  the  subject  has  never  borne  a  child.  The  cervix  in  the 
parous  is  not  conical  as  in  the  virgin,  but  often  club-shaped,  the  mouth 
larger,  and  fissures  can  be  seen  and  felt,  the  most  distinct  usually  being 
transverse;  that  upon  the  left  side  is  more  invariable  and  generally  more 
distinct,  and  its  greater  depth  and  more  uniform  presence  are  explained 
by  the  greater  frequency  of  left  occipito-anterior  positions.  Childbear- 
ing  also  shortens  the  neck  of  the  womb,  and  in  a  woman  who  has  had 
many  children  the  vaginal  portion  of  the  neck  may  be  so  lessened  as 
scarcely  to  project  in  the  vagina. 

The  cavity  of  the  uterus  is  divided  into  that  of  the  body  and  that  of 
the  neck,  the  dividing- line  being  a  narrowed  part  corresponding  inter- 
nally with  the  isthmus  externally  ;  this  internal  narrowed  part  is  known 
as  the  os  uteri  internum,  the  internal  mouth  of  the  womb. 

THE  CAVITY  OF  THE  BODY  OF  THE  UTERUS.  The  cavity  of  the 
body  of  the  uterus  is  triangular,  the  angles  being  at  the  entrance  of  the 
oviduct  on  each  side  and  at  the  internal  os  uteri.  The  sides  of  this 
triangle  are  convex,  the  curve  being  toward  the  centre  of  the  cavity  in 
the  nulliparous ;  the  sides  are  straight,  or  even  curved  somewhat  out- 
ward in  the  parous.  The  anterior  and  posterior  walls  are  in  contact, 
or  else  separated  by  only  a  thin  layer  of  mucus.  The  capacity  of  the 
uterine  cavity  in  the  nulliparous  is  from  2  to  3  cubic  centimetres,  or  32 
to  49  minims;  in  the  parous  3  to  5  cubic  centimetres,  or  49  minims  to 
1  drachm  21  minims. 

THE  CAVITY  OF  THE  NECK.  The  cavity  of  the  neck  is  fusiform ; 
but  this  character  is  less  distinct  in  the  parous  than  in  the  virgin.  The 
anterior  and  posterior  walls  have  each  a  longitudinal  projection,  the  two 
projections  not,  however,  directly  opposite;  from  each  of  these  as  a 


60 


PHYSIOLOGY  OF  PREGNANCY. 


central  axis  similar  projections,  plicce  palmatce,  pass  obliquely  on  either 
side ;  each  axis  with  its  branches  forms  an  arbor  vitce — arbor  uteri  vivi- 
ficans  was  the  name  given  it  by  the  old  anatomists.  In  addition  to  the 
median  ridges  or  columns,  there  is  one  on  each  side  at  the  junction  of 
the  anterior  and  posterior  walls. 

THE  STRUCTURE  OF  THE  UTERUS.  The  walls  of  the  uterus  are 
composed  of  an  external  serous,  an  internal  mucous,  and  a  middle  mus- 
cular coat.  The  thickness  of  the  uterine  parietes  varies  at  different 
parts  from  four-thirteenths  to  seven-thirteenths  of  an  inch,  eight  to 
fifteen  millimetres ;  the  wall  is  thinnest  at  the  entrance  of  the  oviducts, 
thickest  at  the  sides. 


FIG.  28. 


FIG.  29. 


TRANSVERSE  SECTION  OF  A  NULLIPAROUS 
UiERrs. 


TRANS  VERSE  SECTION  OP  A  MULTIPAROUS  UTERUS. 
A.  Cavity  of  the  neck  and  arbor  vitse.    C.  Cavity 
of  the  body.     0.  Isthmus  separating  body  and 
neck.    S.  Uterine  tissue. 


THE  PERITONEAL  COAT.  All  the  uterus  is  covered  with  peritoneum 
except  its  borders,  that  part  which  is  within  the  vagina — that  is,  the 
vaginal  portion,  the  part  connected  with  the  bladder,  and  that  to  which 
the  vagina  is  attached.  The  union  is  so  intimate  upon  the  anterior  and 
upon  the  posterior  face  of  the  uterus  that  even  a  small  part  of  the 
serous  cannot  be  removed  without  taking  away  also  a  thin  layer  of 
muscular  tissue.  The  peritoneum  is  reflected  from  the  uterus  in  front 
over  the  bladder,  and  in  this  reflection  the  vesico-uterine  cul-de-sac  is 
formed;  its  reflection  posteriorly  over  the  rectum  forms  the  retro- 
uterine  cul-de-sac,  the  lowest  portion  of  the  peritoneal  cavity;  laterally 
the  anterior  and  posterior  layers  of  the  peritoneum  which  include  the 
uterus  meet  to  form  the  broad  ligaments. 

In  some  cases  the  posterior  peritoneal  reflection  begins  upon  that  part 
of  the  posterior  surface  of  the  cervix  which  corresponds  with  the  internal 
os;  in  most,  however,  the  peritoneum  descends  so  as  to  be  in  relation 
for  a  short  distance  with  the  upper  posterior  vaginal  wall,  and  then  is 
reflected  over  the  rectum. 


THE  FEMALE  SEXUAL  ORGANS.  01 

THE  MUSCULAR  COAT.  This  is  the  most  important  of  the  three, 
and  makes  almost  the  entire  thickness  of  the  uterine  wall ;  the  uterus 
is,  in  fact,  a  hollow  muscle.  The  muscular  tissue  of  the  non-pregnant 
uterus  is  firm,  resisting,  has  a  grayish  or  reddish-gray  color,  and  when 
cut  creaks  like  firm  fibrous  tissue.  But  this  organ  in  pregnancy  shows 
marked  changes  in  its  muscular  substance.  The  tissue  is  now  softened, 
very  vascular,  and  red  ;  in  consequence  of  both  hypertrophy  and  hyper- 
plasia  its  muscular  character  has  become  quite  distinct. 

Most  authors  describe  the  muscular  wall  of  the  uterus  as  composed 
of  three  layers — one  external,  a  middle,  and  an  internal.  The  usual 
description  will  be  briefly  given  first,  and  then  some  results  of  recent 
studies  of  this  wall  will  be  presented. 


FIG.  30. 


FIG.  31. 


EXTERNAL  MUSCULAR  LAYER  OF  POSTERIOR 
WALL  OF  UTERUS. 


INTERNAL  MUSCULAR  LAYER. 
a.  Section  of  uterine  wall.     b.   Triangular 
bundle,   c.  Fibres  returning  to  the  tubes,   e,  e. 
Transverse  fibres,    v.  Vagina. 


The  external  layer  is  formed  by  alternate  planes  of  transverse  and 
longitudinal  fibres. 

On  the  posterior  wall  transverse  bundles  are  found  beginning  at  each 
side  at  the  level  of  the  isthmus;  running  across  toward  the  median  line, 
they  then  turn  abruptly  to  become  longitudinal ;  fresh  accessions  to  the 
latter  come  from  the  inflection  of  other  fibres  from  either  side  in  the 
ascent  from  the  isthmus  toward  the  fundus.  The  median  portion  of 
the  bundles  of  longitudinal  fibres  pass  over  the  fundus,  but  the  fasciculi 
cross  each  other,  those  from  the  left  passing  to  the  right,  and  similarly 
the  right  passing  to  the  left,  to  descend  upon  the  anterior  wall ;  the 
lateral  bundles  pass  off  to  the  broad  ligaments  and  to  the  oviducts. 

The  deep  or  internal  layer  is  chiefly  formed  of  orbicular  fasciculi, 
having  the  openings  of  the  tubes  as  centres,  and  arranged  in  concentric 
circles.  At  the  level  of  the  isthmus  more  or  less  complete  rings  are 


62  PHYSIOLOGY  OF  PREGNANCY. 

found,  making  a  sphincter.  There  also  enter  into  the  formation  of  this 
coat  two  triangular  fasciculi — one  on  the  anterior,  the  other  on  the  pos- 
terior wall ;  the  base  of  each  triangle  is  at  the  fundus  and  its  apex  at 
the  isthmus ;  these  fasciculi  begin  in  transverse  fibres  below  and  end  in 
transverse  fibres  above,  so  that  the  general  course  of  the  twice-inflected 
fasciculi  is  represented  by  the  letter  Z ;  but  the  course  of  the  fasciculi 
upon  the  anterior  wall  is  the  reverse  of  that  of  those  upon  the  posterior 
wall — that  is,  it  would  be  represented  by  an  inverted  £• 

The  middle  layer,  found  only  in  the  body  of  the  uterus,  is  as  thick 
as  the  two  others  united.  Tarnier  gives  the  following  description  :  It 
is  composed  of  bands  of  variable  size  which  cross  each  other  in  every 
direction  ;  some  are  transverse,  others  oblique,  some  longitudinal ;  large 
apertures,  traversed  by  veins  and  sinuses,  separate  these  bands  from 
each  other,  or  separate  the  fibres  of  the  same  band.  Muscular  fasciculi 
are  curved  around  the  uterine  veins  (the  arciform  fibres  of  William 
Hunter,  1772;  fibres  in  anse  of  Calza,  1807),  and  each  curve  crossed 
by  another  forms  with  it  a  complete  ring  which  encircles  the  vein.  A 
series  of  these  rings  makes  a  canal  for  the  vein.  Large  rings,  similar 
in  their  formation  to  the  preceding,  encircle  several  veins  at  a  time,  and 
each  of  the  latter  in  the  chief  ring  also  has  its  own  ring.  Most  fre- 
quently the  curved  fasciculus  forms  only  one-half  or  two-thirds  of  the 
circle,  which  another  fasciculus  completes  by  crossing  the  first,  with 
which  it  is  intimately  united.  Each  venous  vessel  is  thus  surrounded 
by  contractile  annular  fibres,  and  passes  in  a  true  contractile  canal  in  all 
its  course  through  the  middle  layer. 

FIG.  32. 


b 

MIDDLE  MUSCULAR  LAYER  AT  THE  FUNDUS. 
a,  a.  Superficial  layer  dissected  back.    b.  Branches  belonging  to  the  inner  layer,    t,  t.  Tubes. 

The  muscular  tissue  of  the  neck  is  derived  solely  from  the  external 
and  from  the  internal  layers.  Its  superficial  muscular  plane  is  formed 
exclusively  of  transverse  fibres,  the  fasciculi  crossing  each  other  at  the 
median  line  according  to  Schwartz ;  but  Tarnier  and  others  describe 
them  as  passing  somewhat  obliquely.  Muscular  fibres  pass  from  the 
neck  to  the  vagina,  to  the  utero-sacral  and  to  the  utero-vesical  liga- 
ments. Immediately  beneath  the  mucous  membrane  of  the  cervical 
canal  fibres  of  muscular  tissue  are  found.  The  projections  of  the  arbor 
vitce  are  for  by  muscular  fasciculi,  whose  fibres  separate  on  each  side  in 
making  the  superposed  arches. 

Bayer,  from  a  very  careful  microscopic  study  of  the  muscular  struct- 


THE  FEMALE  SEXUAL  ORGANS.  63 

ure  of  the  non-gravid  uterus,  has  been  led  to  the  following  conclu- 
sions :l 

1.  The  internal  longitudinal  fibres  of  the  oviducts  form  the  largest  part  of  the 
submucous  muscular  layer  of  the  uterus,  while  their  external  longitudinal  layers 
form  a  part  of  the  external  layer.     The  circular  fibres  of  the  oviducts  assist  in 
the  formation  of  the  middle  muscular  layer  of  the  uterus. 

2.  The  greater  portion  of  the  muscular  tissue  of  the  lower  pole  of  the  uterus 
and  of  the  cervix  is  developed  from  the  retractors.2 

The  lowest  and  thickest  part  of  the  posterior  wall  of  the  corpus,  a  thinner  and 
higher  zone  on  the  anterior  Avail,  the  whole  of  the  lateral  wall  of  the  cervix,  as 
well  as  the  anterior  lip,  and  the  portion  of  the  cervix  immediately  above  it,  may 
be  traced  to  this  origin. 

3.  The  remaining  portion  of  the  uterine  fibres  is  derived  from  the  radiating 
fibres  of  the  round  ligament,  and,  indeed,  the  chief  mass  of  the  posterior  wall  of 
the  body  from  the  retractors ;  and  the  muscle  bundles  surrounding  both  angles 
of  the  womb  in  diverse  layers  are  derived  from  the  ovarian  ligament ;  on  the 
other  hand,  the  external  layer  of  the  anterior  wall  and  the  lower  part  of  the 
cervix  and  the  entire  supra-vaginal  part  lead  back  to  the  round  ligament.     The 
middle  layer  of  the  body  is  formed  by  both  ligaments  in  common. 

It  will  thus  be  seen  that  a  general  division  of  the  muscular  mass  of 
the  womb  into  three  or  more  layers  is  not  feasible,  since  the  arrangement 
of  the  muscular  layers  is  diverse  in  different  parts  of  the  uterus.  Its 
construction  can  only  be  understood  by  examining  the  several  portions 
of  the  uterus  separately. 

1.  The  fund  us  is  composed  of — 

(a)  A.  superficial  layer,  the  median  longitudinal  fibres  of  which  pass 
from  in  front  back,  while  the  lateral  fibres  are  arranged  in  whorls  around 
the  insertions  of  the  oviducts ;  these  whorls  pass  from  left  to  right  around 
the  right  tube,  from  right  to  left  around  the  left  tube,  compared  with  the 
direction  in  which  the  hands  of  a  watch  move ;  a  hood-like  covering  is 
thus  formed,  probably  arising  from  the  external  longitudinal  layer  of 
the  oviduct,  and  of  the  round  ligament. 

(6)  Of  the  deepest,  or  submucous  layer,  arranged  in  the  same  manner 
as  the  above,  and  derived  from  the  internal  longitudinal  fibres  of  the 
oviduct. 

(c)  Of  a  middle  layer,  which  is  derived  from  the  round  and  from  the 
ovarian  ligaments,  a  broad  band,  anteriorly  and  posteriorly,  on  both  sides 
of  the  median  line,  passing  in  a  sagittal  direction.  This  is  interlaced 
with  transverse  bands  from  the  circular  fibres  of  the  oviducts.  Fibres 
from  the  ovarian  ligament,  in  connection  with  the  latter,  surround  the 
horns  of  the  uterus  in  spirals  and  obliquely  placed  circulars. 

2.  The  posterior  wall  is  formed  by  the  circular  fibres  of  the  oviduct, 
by  diagonal  lamellae  from  the  ovarian  ligament,  which  pass  inward  from 
above,  and,  finally,  by  the  eccentric  rings  coming  from  the  retractors, 
which  penetrate  all  the  layers.     In  this  description  the  most  superficial 
and  the  deepest  longitudinal  fibres  originating  from  the  oviducts,  and 
which  unite  to  form  anteriorly  and  posteriorly  a  triangular  muscle,  are 
omitted. 

3.  The  middle  part  of  the  anterior  wall  may  be  divided  into  an 
external  longitudinal  layer,  which  arises  from  the  muscular  fibres  of  the 

1  Morpholqgie  der  Gebarmutter.    Freund's  Gynakologische  Klinik.    Strassburg,  1885. 
8  See  description  of  the  utero-sacral  ligaments. 


64 


PHYSIOLOGY  OF  PREGNANCY. 


round  ligament,  united  with  the  longitudinal  fibres  from  the  oviduct ; 
a  middle  layer  formed  by  the  union  of  circular  fibres  from  the  oviduct 
with  the  anterior  rings  of  the  retractors,  and  an  internal  longitudinal 
layer  formed  by  the  crossing  anteriorly  of  the  inner  longitudinal  fibres 
of  the  oviducts. 

4.  In  the  lower  part  of  the  body,  the  greater  part  of  the  walls  is 
formed  by  muscular  bands  from  the  round  ligament. 

5.  In  the  internal  and  external  portion  of  the  cervix  longitudinal 
fibres,  which  are  the  continuation  of  the  corresponding  layers  of  the 
corpus,  anteriorly  and  posteriorly  pass  in  the  median  line.     Beside  this, 
the  posterior  wall  of  the  cervix  essentially  consists  of  eccentric  rings  of 
the  retractors,  the  interlacing  fibres  of  which  form  other  parts,  and 
finally,  externally  of  fasciculi  from  the  ovarian  ligaments,  which  after 
passing  longitudinally  are  inflected. 

In  the  anterior  wall  of  the  cervix  only  muscular  lamellae,  running 
diagonally  toward  the  mucous  membrane,  and  covering  each  other  like 
the  tiles  of  a  roof,  can  be  recognized ;  the  fibres  of  the  retractors  are 
found  more  especially  in  the  lower  third,  forming  a  compact  muscular 
mass  by  interlacing  with  the  radiating  fibres  from  the  round  liga- 
ment. 

Bayer  remarks  that  if  these  manifold  convolutions  of  the  muscular 
fibres  make  the  picture  of  the  uterus  a  very  complicated  one,  the  vessels 
which  pass  in  every  direction  and  render  the  preparation  of  the  mus- 
cular layers  exceedingly  difficult,  render  it  still  more  complex.  The 
most  vascular  portions  are  the  posterior  and  lateral  walls  of  the  corpus 
and  the  entire  posterior  wall  and  the  anterior  lip  of  the  cervix. 

Fig.  38  represents  the  internal  surface  of  the  uterus  exposed  by  an 
incision  through  the  middle  of  the  anterior  wall.  The  uterine  portion 

of  each  oviduct  is  seen,  surrounded  by 
a  system  of  circular  fibres  which  pass 
anteriorly  and  posteriorly  into  a  median 
strip  of  longitudinal  fibres.  The  lower 
portions  of  the  sides  are  covered  with 
horizontally  arranged  circular  segments 
which  project  sharply  above  the  level 
of  the  surface,  and  turn  slightly  upward 
as  they  approach  the  median  line  above 
mentioned.  Careful  examination  shows 
that  the  posterior  longitudinal  fibres 
go  outward,  and  the  lateral  fibres,  after 
passing  toward  the  horn  of  the  uterus 
above  the  opening  of  the  oviduct, 
curve  around  it  and  enter  its  wall  at 
the  lower  margin.  The  anterior  median 
line  of  fibres,  however,  arches  under  the 
orifice  of  the  oviduct,  and  these  fibres 
disappear  in  the  posterior  and  upper  margin.  The  middle  or  central 
fasciculi  pass  directly  over  the  fundus,  in  vertical  arches,  to  the  posterior 
wall.  The  circular  systems  around  the  orifices  of  the  oviducts,  there- 
fore, appear  to  be  composed  of  two  spiral  systems  which  wind  around 


FIG.  33. 


INTERNAL  SURFACE  OF  THE  UTERUS, 
AS  SHOWN  AFTER  INCISION  IN  THE  MEDIAN 
LINE  OF  THE  ANTERIOR  WALL. 


THE  FEMALE  SEXUAL  ORGANS. 


65 


from  the  interior  of  the  oviduct  toward  the  anterior  and  posterior  walls 
of  the  corpus. 

These  fibres  describe  only  a  semicircle  about  the  orifice  of  the  ovi- 
ducts, and  it  is  by  the  union  of  the  two  systems  that  complete  circles 
are  formed. 

THE  Mucous  MEMBRANE  OF  THE  UTERUS.  The  mucous  mem- 
brane of  the  body  differs  from  that  of  the  neck,  and  will  be  first 
described.  It  is  a  pale  pink  in  life,  but  becomes  a  grayish  color  after 
death,  and  is  moist  from  its  abundant  glandular  secretion.  It  has  a 
thickness  of  0.039  to  0.078  inch,  two  to  four  millimetres,  in  the  virgin 
uterus,  0.23  to  0.31  of  an  inch,  six  to  eight  millimetres,  in  the  parous 
uterus;  it  is  thinner  in  the  vicinity  of  the  entrance  of  the  oviducts 
than  elsewhere.  It  is  greatly  swelled  during  menstruation,  so  that  its 
thickness  is  two  or  three  times  greater.  Its  free  surface  is  smooth,  and 
upon  it  the  mouths  of  the  uterine  glands  open ;  these  glands  are  so 
numerous  that  their  openings  occupy  nearly  one-third  of  the  entire 
surface. 

FIG.  34. 


GLANDS  OF  THE  BODY  OF  THE  UTERUS. 
a,  a.  Free  mucous  surface  of  the  uterus,  with  mouths  of  glands  opening  in  it.    d,  d.  Glands. 

The  mucous  membrane  is  so  intimately  attached  to  the  muscular 
tissue  that  it  is  impossible  to  separate  them ;  there  is,  according  to 
Cadiat,  an  actual  reciprocal  penetration.1  A  single  layer  of  cylindrical 
ciliated  epithelium  is  found  upon  the  free  surface ;  the  movements  of 
the  cilia  are  from  the  mouth  of  the  uterus  toward  the  oviducts.  Beneath 
this  there  is  found  amorphous  matter  containing  a  large  number  of  fibro- 
plastic  bodies. 

UTRICULAR  GLANDS.  These  glands  are  cylindrical  and  flexuous. 
Engelmanu  states  that  they  are  often  bifurcated  at  their  lower  third,  but 
according  to  de  Siue'ty  they  are  rarely  bifurcated,  and  Sappey  describes 
them  as  generally  single,  sometimes  bifid  or  trifid.  They  are  lined 
with  ciliated  epithelium,  and  secrete  a  transparent,  alkaline,  fluent 
mucus. 

Mucous  MEMBRANE  OF  THE  NECK.  This  is  whiter,  thinner,  and  of 
firmer  .consistence  than  is  that  of  the  body.  Cylindrical  epithelium 
with  vibratile  cilia  is  found  in  the  upper  two-thirds,  but  in  the  lower 
third  pavement-epithelium.  The  borders  of  the  elevations  caused  by 
the  arbor  vitce  are  lined  by  ciliated  epithelium.  But  in  passing  from 
the  free  borders  to  the  sides  of  the  elevations  referred  to,  the  ciliated 

1  Schwartz. 
5 


66 


PHYSIOLOGY  OF  PREGNANCY. 


is  replaced  by  cup-shaped  epithelium  which  becomes  more  aud  more 
developed  as  it  penetrates  more  profoundly  into  the  numerous  glands 
situated  at  the  fundus  of  a  mucous  fold.1  The  glands,  which  are  so 
abundant  in  the  cervix  that  Spiegelberg  calls  it  a  great  gland  apparatus, 
are  not  tubular,  like  those  of  the  corpus,  but  racemose.  The  glands  of 
the  cervix  secrete  a  thick,  viscid  alkaline,  gelatin-like  mucus  ;  it  forms 
the  gelatinous  plug  that  in  pregnancy  is  frequently  found  filling  the 
cervical  canal.  No  glands  are  found  at  the  level  of  the  external  mouth 
of  the  womb.  Obstruction  of  the  excretory  duct  of  one  of  the  cervical 
glands  gives  rise  to  retention  by  the  accumulation  of  secretion ;  and 
such  cysts  are  known  as  ovula  Nabothi,  because  of  Naboth's  error  in 
regarding  them  as  human  eggs. 


FIG.  35. 


FIG.  36. 


EPITHELIUM  WITH  VIBRATILE  CILIA. 

(350  Diameters.) 

a.  Nucleus,    b.  Nucleolus.    c.  Body  of  the  cell.    v.  Vibratile 
cilia. 


VERTICAL  SECTION  OF  THE  Mu- 
.cous  MEMBRANE  OF  THE  VIRGIN 
UTERUS. 

S.  Mucous  membrane.  D.  Uter- 
ine glands.  M.  Muscular  stra- 
tum. 


EPITHELIUM  WITH  CUP-SHAPED  CELLS.    (350  Diameters.) 

a.  Nucleus,     b.  Nucleolus.    c.  Body  of  the  cell  forming  a 

cavity. 


Beneath  the  epithelium  there  are  fibrous2  laminae  which  are  continu- 
ous with  those  interposed  between  the  muscular  fasciculi,  and  hence 
the  intimate  union  between  the  mucous  membrane  and  the  subjacent 
tissue. 

BLOODVESSELS  OF  THE  UTERUS.  The  four  chief  trunks  supplying 
blood  to  the  uterus  are  the  two  uterine  and  the  two  ovarian  arteries. 
The  two  latter,  which  correspond  to  the  spermatic  in  the  male,  not  only 
carry  blood  to  the  uterus,  but  also  to  the  ovaries  and  to  the  oviducts. 
In  addition  to  the  arteries  mentioned,  a  branch  from  the  epigastric,  on 
each  side,  passes  through  the  round  ligament  to  the  uterus.  On  account 
of  the  number  and  volume  of  the  arterial  currents  supplying  the  uterus, 
this  organ  has  been  compared  to  the  brain.  The  uterine  arteries  are 
given  off  by  the  internal  iliacs,  while  the  ovarian  proceed  directly  from 
the  aorta  just  below  the  renal.  The  uterine  artery,  pursuing  a  remark- 
ably flexuous  course,  enters  the  base  of  the  broad  ligament,  and  at  the 
middle  of  the  cervix  gives  off  two  branches,  one  of  which  passes  in  front 
of,  the  other  behind  the  cervix,  to  unite  with  corresponding  branches  de- 
rived from  the  other  uterine  artery,  thus  making  a  complete  anastomosis, 
and  at  the  same  time  forming  an  arterial  ring  which  encircles  this  portion 


De  Sin6ty. 


2  Schwartz. 


THE  FEMALE  SEXUAL  ORGANS. 


67 


of  the  uterus.  The  chief  trunk  ascends,  and  at  the  level  of  the  fundus 
gives  off  a  large  number  of  branches,  which  enter  beneath  the  peritoneum 
into  the  muscular  tissue  to  pass  to  the  mucous  layer,  becoming  capillaries 


FIG.  38. 


THE  OVARIAN,  UTERINE,  AND  VAGINAL  ARTERIES.    (HYRTL.) 

a.  Ovarian  artery,    a'  and  6'.  Branches  to  tube.    6.  Branch  to  round  ligament,    c.  Uterine 
artery,    c'.  Branches  to  ovary,    g.  Vaginal  artery,    h.  Azygos  artery  of  vagina. 


in  the  muscles,  and  forming  a  fine  network  around  the  glandular  culs- 
de-sac.  The  uterine  artery  anastomoses  with  the  ovarian,  forming  a 
large  arch.  The  ovarian  is  chiefly  distributed  to  the  fundus  and  the 


68  PHYSIOLOGY  OF  PREGNANCY. 

upper  part  of  the  body  of  the  uterus.  Both  the  uterine  and  the 
ovarian  arteries  are  remarkable  for  their  serpentiue  course  or  cork- 
screw form. 

Uterine  veins,  which  anastomose  with  each  other,  collect  the  blood 
from  mucous  and  muscular  capillaries.  They  are  generally  large,  but 
in  pregnancy  so  increased  in  size  that  they  are  called  sinuses;  their 
walls  are  firmly  fastened  to  the  muscular  framework  of  the  uterus  by 
strong  connective  tissue,  and  thus  "  thousands  of  living  ligatures  "  are 
provided  for  the  arrest  of  hemorrhage  after  detachment  of  the  placenta  ; 
the  construction  of  the  middle  muscular  coat  of  the  uterus,  with  rela- 
tion of  the  veins  which  traverse  it,  seems  to  have  been  especially  designed 
for  this  purpose.  Emerging  from  the  uterus  at  its  sides,  the  veins  freely 
anastomose  so  that  a  large  plexus  is  formed  on  each  side,  enclosed  in  the 
folds  of  the  broad  ligament,  known  as  the  utero-ovarian  plexus ;  this 
plexus  is  dilated  in  menstruation  and  in  all  other  conditions  of  uterine 
congestion.  Four  veins — two  uterine  and  two  ovarian — carry  the  blood 
from  these  plexuses  ;  the  uterine  empty  into  the  internal  iliac  veins,  the 
left  ovarian  into  the  left  renal,  and  the  right  ovarian  directly  into  the 
vena  cava.  Veins  also  pass  through  the  round  ligaments  and  empty 
into  the  epigastrics  or  into  the  external  iliacs. 

The  erectility  of  the  uterus  is  claimed  to  result  from  the  disposition 
of  its  arteries  and  veins.  Rouget  showed  that  when  its  veins  were 
injected  it  became  erect,  swollen,  its  size  greater,  and  its  cavity  increased 
by  the  separation  of  its  walls.  This  erection  is  by  some  supposed  to 
occur  during  coition,  and  to  facilitate  the  entrance  of  spermatozoids  into 
the  uterine  cavity. 

THE  LYMPHATICS  OF  THE  UTERUS.  These  have  been  divided  into 
three  sets  or  systems,  viz. :  a  subserous,  a  muscular,  and  a  mucous. 
The  last  has  no  vessels,  but  is  composed  of  numerous  and  large  lymph 
spaces,  so  that  the  mucous  membrane  has  been  called  an  enormous 
lymph  gland  ;  these  spaces  freely  communicate  with  each  other ;  they 
are  formed  by  trabecula?  lined  with  endolitheum,  and  encircle  the  vessels 
and  glandular  culs-de-sac;  they  communicate  with  the  lymphatic  vessels 
of  the  muscular  wall. 

The  lymphatic  system  of  the  muscular  coat  is  arranged  in  three  planes 
— internal,  middle,  and  external.  The  first  is  composed  of  cylindrical 
vessels  running  transversely,  placed  between  the  muscular  fasciculi,  and 
uniting  the  submucous  lymph  set  with  the  middle  muscular  plane.  The 
second  plane  is  composed  of  vessels  provided  with  valves,  and  which 
are  tortuous ;  these  convey  the  lymph  to  the  vessels  of  the  broad  liga- 
ments. The  third,  or  superficial  muscular  plane,  consists  of  vessels 
placed  longitudinally  between  the  muscular  fasciculi ;  they  furnish  com- 
munication between  the  large  trunks  of  the  middle  layer  and  the  sub- 
peritoneal  lymphatics.  The  subperitoneal  lymphatics  are  found  upon 
the  anterior  and  upon  the  posterior  face  of  the  uterus,  and  at  its  sides. 
Those  of  the  neck  form  a  large  subperitoneal  plexus,  and  then  unite  in 
vessels  which  communicate  with  the  lateral  and  sacral  ganglia.  Accord- 
ing to  Championniere,  a  ganglion  is  found  on  each  side  of  the  uterus  at 
the  isthmus,  and  this  fact  is  regarded  as  of  importance  in  connection 
with  the  development  of  certain  puerperal  diseases.  The  subperitoneal 


THE  FEMALE  SEXUAL  ORGANS. 


69 


lymphatics  of  the  body  of  the  uterus  are  large  vessels  provided  with 
valves  ;  those  at  the  sides  directly  enter  the  lymphatic  vessels  of  the 
broad  ligaments,  and  those  upon  the  anterior  and  posterior  face  indi- 
rectly through  the  vessels  of  the  middle  muscular  plane. 

THE   NERVES   OF   THE   UTERUS.     The  plexus  uterinus  magnus, 
formed   by  branches  from   the  superior  mesenteric  plexus  and    from 


FIG.  39. 


THE  NERVES  OF  THE  UTERUS.    (FRANKENHAUSER.) 

A.  Plexus  uterinus  magnus.    B.  Plexus  hypogastricus.    1.  Sacrum.    2.  Rectum.    3.  Bladder. 
4.  Uterus.    5.  Ovary.    6.  Fimbriated  extremity  of  tube. 

the  ovarian  ganglia,  which  receive  large  branches  on  both  sides  from 
the  fourth  sympathetic  ganglion,  is  situated  at  the  bifurcation  of  the 
abdominal  aorta.  An  inch  and  a  half,  3.79  centimetres,  below  the 
bifurcation,  directly  at  the  promontory,  this  plexus  divides  into  two 
branches  which  pass  right  and  left  about  the  rectum,  and  go  to  the 


70  PHYSIOLOGY  OF  PREGNANCY. 

upper  part  of  the  vagina  and  the  uterus;  these  two  branches  are  the 
hypogastric  plexus.  They  receive  numerous  filaments  from  the  fifth 
lumbar  ganglion,  and  from  the  first,  second,  and  third  sacral  ganglia  of 
the  sympathetic.  When  they  have  reached  the  side  of  the  rectum  the 
hypogastric  nerves  divide  into  two  unequal  branches.  The  smaller  of 
these  remains  at  the  inner  side  of  the  pelvic  vessels  and  is  distributed 
to  the  posterior  and  lateral  parts  of  the  uterus.  The  larger  branch  goes 
under  the  vessels,  and  passes  partly  to  the  large  cervical  ganglion  and 
in  part  unites  with  the  sacral  nerves.  The  cervical  ganglion  in  preg- 
nancy is  nearly  two  inches  long,  5  centimetres,  and  an  inch  and  a  half 
broad,  3.79  centimetres ;  it  is  situated  at  the  side  of  the  posterior 
vaginal  vault,  and  is  formed  from  both  hypogastric  plexuses,  from  the 
first  three  sacral  ganglia,  and  from  the  second,  third,  and  fourth  sacral 
nerves.  It  supplies  the  entire  uterus,  and  especially  the  cervix,  with 
nerves. 

The  mode  of  termination  of  the  nerve  fibres  in  the  mucous  membrane 
is  unknown ;  in  the  muscular  tissue  this  termination  is,  according  to 
Frankenhauser,  in  the  nuclei  of  the  muscle  cells.  No  ganglia  are 
found  in  the  intra-muscular  nerve  plexuses  of  the  uterus,  and  in  this 
regard  there  is  a  remarkable  contrast  between  these  plexuses  and  those 
of  the  stomach  and  intestines,  which  are  very  rich  in  ganglia.  Physio- 
logical experiment  has  proved  the  presence  of  vaso-dilating  and  vaso- 
constricting  nerves  in  the  uterus.1  Kleinwachter  remarks  that  a  knowl- 
edge of  the  nerve  distribution  does  not  explain  the  way  by  which  uterine 
contractions  are  produced. 

Spiegelberg  has  stated  that  while  a  motor-centre  for  the  uterus  is  found  in  the 
medulla  oblongata,  this  centre  is  not  the  only  one  which  controls  the  action  of 
the  uterus,  and  at  most  is  a  reflex  one,  and  that  there  are  independent  centres 
for  uterine  contractions  in  the  lumbar  spinal  cord ;  but  he  also  stated  that  there 
are  facts  which  show  that  the  uterus  is,  to  a  certain  extent,  independent  of  the 
spinal  centres.  Dembo 2  observes  there  is  not  a  point  in  the  cerebro-spinal  sys- 
tem where  a  centre  presiding  over  uterine  contractions  was  not  supposed  to  be 
found.  According  to  some,  the  centre  was  in  the  cerebellum ;  according  to  others, 
in  the  bulb ;  and  still  others  have  found  it  in  both ;  some  place  it  in  the  lumbar 
region  of  the  spinal  cord,  others  at  the  tenth  dorsal  vertebra,  and  others  make 
all  points  of  the  spinal  cord  capable  of  causing  uterine  contractions.  Some  have 
placed  the  centre  in  the  great  sympathetic,  though  differing  as  to  the  part. 
Finally,  some  hold  that  the  uterus  has  its  own  independent  centres.  Among 
recent  investigations  are  those  made  by  the  author  just  quoted,  and  his  conclu- 
sion is  that  most  probably  the  centres  governing  uterine  contractions  are  situated 
beneath  the  peritoneum,  above  the  anterior  wall  of  the  vagina ;  he  has  found 
there  numerous  ganglionic  groups  of  different  sizes,  some  of  them  with  a  hun- 
dred cells  or  more. 

POSITION  or  THE  UTERUS  AND  MEANS  BY  WHICH  THE  ORGAN  is 
SUSTAINED.  The  general  place  in  the  pelvic  cavity  which  the  uterus 
occupies,  and  the  relations  of  the  latter  to  the  bladder  and  the  rectum, 
have  been  mentioned  on  page  58.  The  situation  of  the  uterus  is  not  a 

1  MUller,  Handbuch  der  Geburtshiilfe,  refers  to  a  case  reported  by  Nasse,  in  which  a  primipara 
suffered  witJ|  fracture  of  the  third  and  fourth  cervical  vertebrae  resulting  in  complete  paralysis 
and  anaesthesia,  yet  normal  uterine  contractions  effected  delivery,  and  to  that  of  Abeille,  whose 
patient  had  degeneration  of  the  lumbar  spinal  cord,  the  labor  similarly  ending  spontaneously, 
as  making  questionable  the  statement  that  a  regulator,  or  inhibitory  centre  for  uterine  action, 
is  found  in  the  lumbar  portion  of  the  cord. 

2  Annales  de  Gynecologic,  Feb.  1883. 


THE  FEMALE  SEXUAL  ORGANS. 


71 


fixed  one,  but  there  is  a  great  normal  mobility  provided  for,  so  that  the 
organ  may  change  its  position  according  to  certain  physiological  func- 
tions, and  according  to  the  condition  of  the  neighboring  organs.  Thus 
during  respiration  there  are  alternate  descent  and  ascent  of  the  uterus  ; 
the  position  varies  as  to  the  state  of  the  rectum  and  of  the  bladder ;  it 
is  not  the  same  when  the  subject  is  standing  or  lying  down  ;  it  varies 
in  the  nulliparous  and  parous,  and  when  at  rest,  or  in  the  exercise  of 
its  physiological  functions.  The  most  remarkable  chauge  of  position 
from  a  physiological  cause  is  that  which  occurs  in  pregnancy,  when 
from  having  been  a  pelvic  the  uterus  becomes  almost  entirely  an  abdom- 
inal organ  ;  yet  after  pregnancy  is  over,  and  involution  completed,  it 
occupies  nearly  its  original  position. 


FIG.  40. 


FIG.  41. 


NORMAL  SITUATION  OF  THE  VIRGIN  UTERUS 
WHEN  THE  BLADDER  is  EMPTY. 


POSITION  OF  UTERUS  IN  A  WOMAN  WHO 
HAS  BORNE  A  CHILD. 


Figs.  40  and  41,  from  Schultze,  show  the  position  of  the  uterus  in 
the  virgin,  and  in  the  childbearing  woman,  when  the  bladder  is  empty. 

In  most  instances  the  uterus  is  not  exactly  in  the  transverse  diameter 
of  the  pelvis,  but  a  slight  rotation  occurs  by  which  the  left  side  is 
thrown  toward  the  front  and  the  right  backward.  This  rotation,  which 
becomes  very  marked  in  most  women  during  pregnancy,  is  simply  the 
expression  of  an  embryonic  condition  that  will  be  referred%to  here- 
after. 

Fig.  42,  from  Ramsbotham,  shows  the  position  and  Delations  of  the 
uterus  as  seen  from  above.  The  uterus  is  kept  in  its  normal  position 


72 


PHYSIOLOGY  OF  PREGNANCY. 


by  its  connection  with  the  vagina,  with  the  bladder,  and  with  the  pelvic 
fascia,  and  by  certain  ligaments  which  will  now  be  described. 

THE  UTERINE  LIGAMENTS.  These  are  six  in  number,  three  belong- 
ing to  each  half  of  the  uterus  as  made  by  the  antero-posterior  division. 
They  are  known  as  the  round,  the  broad,  and  the  utero-sacral,  and  each 
is  formed  by  a  fold  of  peritoneum  including  between  the  two  sides 
muscular  and  connective  tissue,  vessels,  and  nerves. 

FIG.  42. 


UTERUS  WITH  ADJACENT  ORGANS,  AS  SEEN  FRO.M  ABOVE. 

a.  Mons  veneris.  6.  Bladder,  c.  Fundus  of  the  uterus,  d.  The  rectum,  e,  e.  The  oviducts. 
g,  g.  The  ovaries,  h,  h.  Posterior  processes  of  broad  ligaments,  i,  i.  Round  ligaments,  k.  Caecum 
with  its  appendages.  1.  Small  intestine,  m.  Body  of  one  of  the  lumbar  vertebrae. 

THK  ROUND  LIGAMENTS.  The  round  ligaments  are  two  cords  cov- 
ered by  peritoneum,  passing  from  the  uterus  at  a  point  a  little  below 
the  origin  of  the  oviducts,  and  at  the  junction  of  the  anterior  face  with 
the  lateral  border  of  the  uterus  to  the  inguinal  canal,  where  their  peri- 
toneal investment  ceases,  and  they  somewhat  change  their  form;  each 
ligament  is  continued  through  the  inguinal  canal,  and  ends  by  an  ex- 
pansion J3f  its  fibres  in  the  upper  part  of  the  labium  majus,  also  to 
mons  veneris.  The  ligament  has  not  only  unstriped,  but  also  striped, 
muscular  fibres;  the  latter  originate  from  the  lower  part  of  the  inguinal 
canal  and  from  the  pubic  spine,  and  are  continued  toward  the  uterus, 


THE  FEMALE  SEXUAL  ORGANS.  73 

but  end  at  the  level  of  the  pelvic  inlet.  The  round  ligament  has  a 
notable  amount  of  connective  and  elastic  tissue,  and  contains  an  artery, 
which,  originating  from  the  epigastric,  passes  on  toward  the  uterus  and 
anastomoses  with  the  uterine  artery,  thus  making  a  connection  between 
the  general  circulation  and  that  of  the  uterus.  Up  to  the  eighth  month 
of  fetal  life  the  peritoneum  is  continued  into  the  inguinal  canal,  making 
the  canal  of  Nuck,  when  it  is  usually  closed ;  should  it  remain  open, 
an  effusion  into  this  peritoneal  prolongation  may  occur,  and  the  disease 
is  known  as  hydrocele  of  the  female.  In  the  non-pregnant  condition 
the  round  ligaments  play  an  important  part  in  preventing  retroversion 
or  retroflexion  of  the  uterus.  During  pregnancy  they  are  remarkably 
increased  in  size,  but  unequally,  and  it  has  recently  been  stated1  that  by 
examining  them  through  the  abdominal  wall,  and  appreciating  their 
development,  a  correct  prognosis  can  be  given  as  to  the  activity  of  the 
labor-pains,  for  that  development  is  a  guide  to  the  muscular  develop- 
ment of  the  uterus.  During  labor  the  contraction  of  the  round  liga- 
ment draws  the  upper  part  of  the  uterus  forward,  securing  economy  of 
force  by  the  direction  given  it  during  uterine  contractions. 

THE  BEOAD  LIGAMENTS.  These  extend  from  the  sides  of  the  uterus 
to  the  sacro-iliac  joints.  They  are  separated  from  each  other  by  the 
intervening  uterus,  but  the  anterior  layer  of  the  one  side  is  continuous 
with  that  of  the  other,  passing  over  the  anterior  face  of  the  uterus ;  in 
like  manner  the  posterior  layers  are  continuous.  Thus  the  pelvic 
cavity,  by  means  of  these  ligaments  and  the  uterus,  is  divided  trans- 
versely into  two  unequal  parts,  the  anterior  being  known  as  the  vesical, 
the  posterior  as  the  rectal.  The  superior  border  of  the  broad  ligament 
presents  three  peritoneal  folds,  known  as  wings — an  anterior,  a  middle, 
and  a  posterior  wing ;  the  first  includes  the  round  ligament,  the  second 
the  oviduct,  and  the  third  the  ovarian  ligament,  which  is  attached  to 
the  inferior  border  of  the  ovary.  At  the  sides  of  the  pelvis  the  peri- 
toneal layers  of  the  broad  ligament  separate,  being  continuous  with 
that  lining  the  pelvis ;  below  a  separation  also  occurs,  the  posterior 
fold  to  be  reflected  over  the  rectum,  the  anterior  over  the  bladder.  At 
the  internal  border  of  the  ligament  the  two  peritoneal  folds  separate  to 
receive  the  uterus.  Large  veins  and  lymphatics  pass  from  the  uterus 
at  this  border.  The  broad  ligaments  contain  between  the  peritoneal  folds 
connective  tissue,  vessels  and  nerves,  and  muscular  fibres;  the  adherence 
of  the  serous  membrane  to  the  muscular  tissue  of  the  uterus  is  so  in- 
timate that  the  former  cannot  be  separated  without  at  the  same  time 
removing  part  of  the  muscular  layer. 

The  broad  ligaments,  beside  assisting  in  the  suspension  of  the  uterus, 
prevent  ite  lateral  deviation,  and  aid  in  restoring  it  to  its  normal  posi- 
tion after  partial  retroversion  caused  by  a  distended  bladder.  During 
pregnancy  the  peritoneal  folds  separate  so  completely  to  accommodate 
the  enlarging  uterus  that  at  the  end  of  gestation  the  broad  ligaments 
have  almost  completely  disappeared. 

THE  PAROVARIUM,  OR  BODY  OF  ROSENMULLER.  If  that  portion 
of  the  recently  removed  broad  ligament,  including  the  oviduct  and  the 

1  Bomburger  :  Gynkkologlsche  Klinik  herausgegeben  von  Dr.  Wilhelm  Alexander  Freund. 
Erster  Band.    1885. 


74  PHYSIOLOGY  OF  PREGNANCY. 

ovary,  be  held  up  to  the  light,  there  will  be  seen  a  series  of  fine  tubes 
passing  to  the  hilum  of  the  ovary,  and  each  terminating  in  a  cul-de-sac; 
above  these,  tubules  communicate  with  a  canal  perpendicular  to  them 
and  parallel  to  the  oviduct.  The  number  of  lubes  is  said  to  be  from 
fifteen  to  eighteen,  but  Doran1  mentions  finding  in  one  specimen 
twenty-four.  The  organ  thus  described  is  called  the  parovarium,  or 
body  of  Rosenmiiller ;  it  is  the  vestige  of  an  embryonic  structure 
known  as  the  body  of  Wolff.  The  efferent  duct  continues  patent  in 
some  of  the  domestic  animals,  and  is  called  the  canal  of  Gartner.  The 
two  urethral  ducts  described  by  Skene  have  been  by  some  thought  to 
be  the  inferior  portion  of  the  efferent  ducts  of  the  parovarium;  the 
development  of  one  form  of  vaginal  cyst  from  Gartner's  canal  is  less 
doubtful. 

THE  UTERO-SACRAL  LIGAMENTS.  These  are  two  semi-lunar  folds 
passing  from  the  uterus  posteriorly  just  above  the  union  of  the  vagina, 
and  attached  to  the  third  and  fourth  sacral  vertebrae  immediately  within 
the  lower  part  of  the  sacro-iliac  joint.  They  form  by  their  superior 
lateral  borders  a  narrowed  passage,  or  mouth  of  Douglas's  cul-de-sac, 
or  the  retro-uterine  peritoneal  pouch,  and  in  some  cases,  where  the  re- 
troverted  uterus  has  sunk  into  this  pouch,  may  hinder  its  restoration. 
These  ligaments  contain  muscular  tissue,  and  are  hypertrophied  in 
pregnancy.  According  to  Luschka,  a  part  of  the  muscular  fibres  of 
each  side  unite  behind  the  cervix,  making  a  half-ring,  and  the  muscle 
formed  by  this  union  is  called  the  muscle  of  Luschka,  or,  with  reference 
to  the  function  assigned  it  by  him,  the  retractor  of  the  uterus.  Schultze 
regards  it  as  the  elevator  rather  than  the  retractor  of  the  uterus,  while 
the  general  action  of  the  folds  is  that  of  a  suspensory  ligament  of  the 
uterus. 

The  utero-sacral  ligaments  are  elongated  in  pregnancy.  Vesico- 
uterine  ligaments  are  also  described  by  some ;  however,  little  importance 
is  attached  to  them  as  means  for  keeping  the  uterus  in  normal  position. 

THE  OVARIES.  These  organs,  of  equal  importance  with  the  testicles 
of  the  male  for  reproduction,  were  called  by  Galen  testes  muliebres. 
They  are  sometimes  classed  as  glandular  organs,  their  supposed  function 
being  to  secrete  ovules ;  but  as  the  ovule  has  to  a  certain  degree  its 
existence  before  the  ovary,  the  latter  serves  as  a  place  of  deposit,  of 
preservation  and  completion  for  the  primordial  ovules,  and  does  not 
secrete,  but  contributes  to  the  evolution  of  these  essential  anatomical 
elements  of  the  organ,  and  for  which  it  is  made. 

NUMBER,  POSITION,  AND  ATTACHMENTS  OF  THE  OVARIES.  The 
ovaries  in  the  human  female,  as  in  almost  all  vertebrates,  are  two ;  in 
birds,2  however,  but  a  single  ovary,  usually  the  left,  is  found,  the  other 
having  atrophied,  this  atrophy  beginning  about  the  seventh  day  of  in- 
cubation. These  organs  are  in  the  pelvic  cavity,  one  on  each  side  of 
the  uterus;  their  long  diameter3  is  not  transverse,  as  is  usually  repre- 
sented, but  parallel  to  the  lateral  pelvic  walls,  and  almost  at  the  level 
of  the  plane  of  the  inlet ;  their  attachment  to  the  pelvis  is  higher  than 
that  to  the  uterus ;  their  superior  border  is  at  the  plane  of  the  inlet,  and 

1  Tumors  of  the  Ovaries,  etc 

2  Duval.  8  Schultze. 


THE  FEMALE  SEXUAL  ORGANS. 


75 


below  the  internal  border  of  the  psoas  and  iliac  muscles.  According 
to  Schultze,  the  contraction  of  the  belly  of  the  combined  psoas  and 
iliacus  muscles  is  the  best  guide  for  the  external  hand  in  bi manual 
palpation  of  the  ovaries ;  and  Charcot  states  that  the  ovarian  pain  of 
the  hysterical  corresponds  most  frequently  with  the  point  of  intersec- 
tion of  two  lines,  the  one  drawn  between  the  superior  anterior  iliac 
spines,  and  the  other  marking  the  prolonged  lateral  boundary  of  the 
epigastrium. 

The  ovaries  are  placed  in  the  posterior  wing  of  the  broad  ligaments  ; 
they  are  behind  the  oviducts  and  in  front  of  the  rectum,  being  usually 
separated  from  the  latter  by  coils  of  intestine.  By  their  relation  with 
the  broad  ligaments  they  are  connected  externally  with  the  pelvic  walls. 
Other  attachments  are  by  the  utero-ovarian,  the  tubo-ovarian,  and  the 
posterior  round  ligaments.  The  utero-ovarian  ligament,  by  some  called 
the  ovarian  ligament,  is  a  cord  composed  of  smooth  muscular  fibres ; 
these  fibres  may  be  followed  into  the  posterior  wall  of  the  uterus,  and 
traced  down  as  far  as  the  internal  os ;  it  passes  from  the  superior  angle 

FIG.  43. 


THE  OVARY  AND  OVIDUCT.    (The  latter  opened  longitudinally.) 

1, 1.  Ovary.  2.  Part  of  the  uterus.  3.  Ovarian  ligament.  4,  4.  Oviduct,  its  walls  opened  by  a 
longitudinal  incision  to  show  the  longitudinal  folds  of  its  lining  membrane.  5,  5.  Pavilion  from 
internal  surface.  6,  6.  Fimbria  attached  to  the  ovary,  or  tubo-ovarian  ligament.  7,  7.  Longitudinal 
folds.  8.  Internal  end  of  the  oviduct. 

of  the  uterus  on  each  side  to  the  internal  end  of  the  ovary.  This  liga- 
ment is  about  one  inch  and  a  quarter,  3.16  centimetres,  in  length. 
That  portion  of  the  broad  ligament  not  occupied  by  the  oviduct  con- 
nects the  ovary  with  the  pelvic  brim,  and  is  known  as  the  iufundibulo- 
pelvic  ligament.  The  ovary  is  thus  suspended  by  and  between  this 
ligament  and  the  ovarian  ;  but  the  pelvic  attachment  is  higher  than  the 
uterine,  and  hence  the  long  diameter  of  the  ovary  is  not  horizontal, 
but  parallel  to  the  lateral  pelvic  wall,  according  to  the  statement  of 
Schultze ;  he  asserts  that  the  long  axis  of  the  ovary  is  nearly  verti- 
cal, a  view  which  is  confirmed  by  Hart  and  Barbour.  The  tubo- 
ovarian  ligament  is  formed  by  the  attachment  of  one  of  the  fringed 
processes  of  the  pavilion  of  the  oviduct  to  the  external  end  of  the  ovary. 
It  is  probable  that  the  superior  surface  of  this  ligament  bears  an  impor- 
tant part  in  the  transfer  of  the  ovule  from  the  ovary  to  the  oviduct. 


76  PHYSIOLOGY  OF  PREGNAXCY. 

The  middle  fibres  of  the  posterior  round  or  lumbar  ligament  pass  to  the 
ovary.  This  ligament,  according  to  Rouget,  is  formed  of  a  lamella  of 
smooth  muscular  fibres  which  originate  from  the  sub-peritoneal  fascia, 
passing  from  behind  forward  to  be  distributed,  the  internal  upon  the 
body  of  the  uterus,  the  external  to  the  pavilion,  and  the  middle  to  the 
hilum  of  the  ovary. 

The  ovary  has  considerable  mobility,  and  hence  the  possibility  of 
both  physiological  and  pathological  changes  of  position,  the  most  re- 
markable of  the  former  being  that  which  occurs  in  pregnancy,  for  the 
ovaries  ascend  with  the  uterus  into  the  abdominal  cavity,  and  afterward 
descend  with  it  into  the  pelvis. 

FORM,  SIZE,  AND  ASPECT  OF  THE  OVARIES.  The  ovary  is  usually 
an  ovoid,  somewhat  flattened  antero-posteriorly ;  its  superior  border  is 
convex,  and  its  inferior  plane ;  its  ends,  or  extremities,  give  attachment 
to  the  ligaments  already  mentioned.  Except  these  attachments,  and  that 
of  the  inferior  border  to  the  peritoneum,  the  organ  is  free.  The  size  of 
the  ovaries  varies  in  individuals  at  different  ages  and  as  to  the  condi- 
tion of  ovulation ;  it  is  greater  during  menstruation  and  during  preg- 
nancy than  at  other  times ;  the  right  ovary  is  usually  somewhat  larger 

t 
FIG.  44. 

U 


BULB  OF  OVAEY. 

than  the  left.  The  average  dimensions  of  the  organ  are,  in  length  1.4 
inches,  38  millimetres;  in  vertical  measurement  0.7  of  an  inch,  18 
millimetres,  and  antero-posteriorly  half  an  inch,  or  15  millimetres.  The 
weight  of  the  ovary  is  from  90  to  120  grains,  or  6  to  8  grammes. 
Doran1  states  that  the  average  weight  of  the  normal  ovary  is  at  least 
100  grains  ;  its  long  axis  is  a  little  over  two  inches,  its  short  axis  one 
inch,  its  thickness  quite  half  an  inch.  The  surface  of  the  ovary  is  white 
and  smooth  at  the  beginning  of  menstrual  life;  it  becomes  uneven  and 
irregular  from  the  cicatrices  of  ruptured  ovisacs,  these  being  more 
numerous  as  age  advances,  and  the  color  changes  to  a  yellowish-brown. 
THE  HILUM  AND  BULB  OF  THE  OVARY.  Between  the  two  layers 
of  peritoneum  which  are  attached  to  the  inferior  border  of  the  ovary, 
the  ovarian  vessels  and  nerves  pass.  The  arteries,  eight  or  ten  in  num- 
ber, derived  from  the  anastomosing  arch  of  the  uterine  and  ovarian, 
have  a  helicine  form  before  entering  the  hilum  of  the  ovary ;  upon  this 

i  Handbook  of  Gynecological  Operations.    Blakiston,  Son  &  Co.,  Philadelphia,  1887. 


THE  FEMALE  SEXUAL  ORGANS. 


77 


FIG.  45. 


layer  of  arterial  vessels  there  is  placed,  in  frout  and  behind,  a  much 
thicker  layer  of  venous  vessels;  an  iujected  specimen  shows  a  large 
mass  of  bloodvessels,  chiefly  venous,  which  communicate  with  the 
pampiniform  plexus  and  with  the  uterine  plexus.  This  is  the  bulb  or 
spongy  body  of  the  ovary;  it  should  not  be  confounded  with  the  bulbous 
portion  of  the  ovary,  which 
will  hereafter  be  described 

STRUCTURE  OF  THE  OVARY. 
It  was  once  generally  held  that 
the  ovary  was  covered  by  peri- 
toneum, and  had  a  tunica  albu- 
ginea,  but  neither  statement  is 
now  regarded  as  true.  The 
researches  of  Waldeyer  have 
shown  that  the  peritoneum 
ceases  at  the  inferior  border  of 
the  organ,  and  that  all  the  rest 
of  its  surface  is  covered  with  a 
simple  layer  of  flattened  cylin- 
drical epithelium ;  this  covering 
presents  a  dull-white  appear- 
ance, which  is  in  striking  con- 
trast with  the  bright,  almost 
shining,  appearance  of  the  peri- 
toneum ;  at  the  inferior  border 
of  the  ovary  there  can  be  seen 
a  finely  notched  line,  marking 
the  place  where  the  latter  ceases 
and  the  former  begins.  The 
supposed  tunica  albugiuea  has 
been  proved  to  be,  instead  of  a 
mere  covering,  the  essential  part 
of  the  organ.  A  vertical  sec- 
tion of  the  ovary  shows  that  it 
is  composed  of  two  very  differ- 
ent substances.  The  superficial 
or  cortical  portion  is  white,  firm, 

i  ,       ,  FROM  AN  OVARIUM  OF  AN  OLD  BITCH.  High  power. 

ana  apparently  homogeneous ;  (STRICTER.) 

the  internal  or    medullary  por-  a.  Germinal  epithelium.     6.  Ovarian  tubes,     c. 

tion  is  reddish,  Spongy,  and  not        Younger  follicles,    d.  Older  follicles,    e.  Proliger- 

homogeneous ;  it  constitutes 
seven-eighths  of  the  organ. 
The  ovisacs  are  found  only  in 
the  superficial  layer,  and  it  is 
therefore  called  by  Sappey  the 
glandular  or  ovigenous  por- 
tion ;  while  the  central  part,  the  great  mass  of  the  organ,  is  called  the 
bulbous  portion ;  by  some  it  is  also  called  the  medullary  portion. 

The  peripheral  or  ovigenous  layer  is  the  essential  part  of  the  ovary ; 
it  is  composed  of  an  external  layer  of  epithelium,  representing  the 


oua  disk,  with  egg.  /.  Epithelium  of  second  egg  in 
the  same  follicle,  g.  Tunica  flbrosa  folliculi.  h. 
Tunica  propria  folliculi.  i,  Epithelium  of  the  fol- 
licle (membrana  granulosa).  I.  Vessels,  m.  Cell 
tubes  of  the  parovarium  in  long  section,  y.  Tubi- 
form  depression  of  the  germinal  epithelium  into 
the  ovarian  tissue. 


78  PHYSIOLOGY  OF  PREGNAXCY. 

germinative  epithelium  of  the  pleuro-peritoneal  cavity  of  embryonic 
life;  of  a  fibrous  framework,  the  fibres  crossing  each  other,  the  super- 
ficial portion  more  dense  than  that  beneath  it,  yet  no  line  of  separation 
between  the  two ;  in  the  meshes  of  this  tissue  the  ovisacs  are  found. 
Only  fifteen  or  twenty  ovisacs  can  be  discovered  by  the  unaided  eye, 
but  the  microscope  reveals  an  almost  infinite  number.  Sappey's  inves- 
tigations have  authorized  him  to  state  that  in  each  ovary  of  a  girl 
eighteen  or  twenty  years  of  age  there  are  more  than  three  hundred 
thousand,  making  some  seven  hundred  thousand  for  the  two ;  in  one 
instance,  that  of  a  girl  four  years  old,  the  number  was  one  million  one 
hundred  and  fifty  thousand.  Nature  is  prodigal  in  supplying  means 
for  the  continuance  of  the  race.  The  bulbous  portion  is  composed  of 
vessels,  nerves,  muscular  and  connective-tissue  fibres  ;  it  furnishes  nutri- 
tive material  to  the  ovisacs  and  ovules,  and  also  a  surface  upon  which 
the  ovisacs  may  be  distributed,  so  as  to  facilitate  their  growth  and  rup- 
ture and  the  reception  of  the  escaping  ovules  by  the  oviduct. 

VESSELS  AND  NERVES  OF  THE  OVARIES.  The  arterial  supply  of 
the  organ,  as  well  as  the  helicine  course  of  the  arteries  before  entering 
the  hilum,  has  been  mentioned.  These  vessels  after  penetrating  the 
ovary  still  preserve  the  helicine  form  ;  they  are  distributed  to  the  bulb- 
ous portion,  and  fine  ramifications  pass  to  the  ovigenous  layer,  but 
scarcely  reach  the  most  external  part ;  vessels,  however,  pass  to  the  walls 
of  ovisacs  that  have  attained  notable  development.  The  veins  are  re- 
markable for  their  size,  varicose  appearance,  and  numerous  anastomoses; 
after  contributing  to  the  formation  of  the  bulb  of  the  ovary,  the  blood 
passes  from  the  bulb  on  either  side  into  the  ovarian  veins.  The  nerves 
are  from  the  ovarian  plexus.  Their  final  distribution  is  not  known ; 
Duval  suggests  that  they  are  especially  designed  for  the  vessels  and  the 
unstriped  muscular  tissue  of  the  bulbous  portion  ;  Luschka  has  seen  an 
axis-cylinder  enter  the  wall  of  an  ovisac.  Large  lymphatic  vessels 
emerge  at  the  hilum  and  pass  to  the  lumbar  ganglia.  It  has  been 
shown  that  the  tissue  about  an  ovisac  is  rich  in  lymph-supply,  so  that, 
as  de  Sinety  remarks,  the  follicle  is  plunged  into  a  closed  lymph  sac, 
a  condition  which  appears  very  favorable  for  nutrition. 

THE  OVISACS.  These  were  discovered  by  de  Graaf,  in  1672,  and 
are  frequently  called  the  Graafian  vesicles  or  follicles ;  but  a  designa- 
tion which  points  to  their  most  important  office,  containers  of  ova,  and 
therefore  ovisacs,  seems  more  appropriate. 

An  ovisac  consists  of  a  capsule,  and  within  the  capsule  the  membrana 
granulosa,  the  liquid  of  the  ovisac,  and  the  ovum.  'The  capsule  is 
described  by  some  as  composed  of  two  layers,  an  external  called  the 
tunica  fibrosa,  and  an  internal  called  the  tunica  propria.  But  as  it  is 
impossible  to  separate  the  supposed  external  one  from  the  surrounding 
ovarian  tissue,  "  from  which  it  does  not  differ  except  from  its  fibres 
being  looser,  and  the  greater  predominance  of  cell  elements,"  most 
authorities  consider  the  capsule  as  having  but  a  single  wall.  This  is  a 
thin,  transparent,  vascular  membrane,  composed,  according  to  Robin, 
of  fibrous  lamina?  pressed  against  each  other,  transparent  amorphous 
matter  with  fine  granulations,  and  large  polyhedric  cells  with  rounded 
angles,  which  are  not  found  elsewhere,  except  in  the  uterine  mucous 


THE  FEMALE  SEXUAL  ORGAXS  79 

membrane  developed  by  pregnancy.  The  liquid  of  the  ovisac,  liquor 
folliculi,  is  clear,  viscid,  alkaline,  and  contains  oil  globules  and  granu- 
lations. 

Upon  the  inner  surface  of  the  capsule  a  layer  of  round  nucleated  cells 
is  found,  constituting  the  membraua  granulosa.  An  accumulation  of 
these  cells  occurs  at  some  part  of  the  ovisac,  forming  the  discus  pro- 
ligerus,  and  in  this  mass  the  ovum  is  found.  The  discus  proligerus  is 
not  usually  at  the  most  projecting  part  of  the  ovisac,  but  at  its  lowest. 
The  ovum,  or  ovule,  discovered  in  1827,  is  spherical,  and  about  y^-g-  of 
an  inch  in  diameter.  It  is  composed  of  three  parts,  an  investing  mem- 
brane, the  vitelline  membrane,  a  granular  liquid,  known  as  the  vitellus, 
a  transparent  vesicle,  the  germinal  vesicle,  and,  finally,  the  germinal 
spot.  The  germinal  vesicle,  or  nucleus  of  the  ovule,  is  T^¥  of  an  inch 
in  diameter,  and  the  germinal  spot,  or  nucleolus,  is  ^yVo  °*  an  ^ncn  m 
diameter. 

THE  OviDUCTS.1  These  are  canals  or  tubes,  placed  one  on  each  side 
of  the  uterus,  through  which  the  spermatozoids  pass  to  or  near  to  the 
ovaries,  and  by  which  the  ovule  is  transmitted  to  the  uterus.  In  rela- 
tion to  the  ovaries,  they  are  its  excretory  ducts.  They  are  in  the  upper 
border  of  the  middle  fold  of  the  broad  ligaments.  An  oviduct  is  be- 
tween four  and  five  inches,  ten  to  twelve  centimetres,  long;  its  diameter 
increases  from  the  uterus  to  the  ovary ;  this  is,  according  to  Sappey,  near 
the  uterus,  0.15  of  an  inch,  or  four  millimetres;  at  its  middle  portion, 
0.19  to  0.22  of  an  inch,  or  five  to  six  millimetres;  and  at  the  abdominal 
opening,  0.27  to  0.31  of  an  inch,  or  seven  to  eight  millimetres.  At  the 
abdominal  end  there  is  an  expanded  portion,  having  a  diameter  of  about 
seven-tenths  to  eight-tenths  of  an  inch,  18  to  20  millimetres,  called  the 
pavilion  or  ampulla.  The  external  surface  of  the  pavilion  is  covered 
by  peritoneum  continuous  with  that  of  the  body  of  the  oviduct;  its 
internal  surface  is  concave,  and  lined  with  ciliated  mucous  membrane; 
its  margin,  where  continuous  with  that  lining  the  oviduct,  meets  serous 
tissue,  is  not  uniform  and  regular,  but  divided  by  numerous  fissures,  so 
that  it  presents  a  fringed  appearance,  and  the  projections  thus  formed 
are  called  fimbrise.  Some  of  the  fimbrise  are  rounded  at  their  free  end, 
others  elongated  and  irregular;  one  of  them  is  without  free  extremity, 
but  is  attached  to  the  ovary,  making  the  tubo-ovarian  ligament ;  and 
hence  the  pavilion  necessarily  follows  the  ovary  in  its  physiological  or 
pathological  changes  of  position;  the  tubo-ovarian  ligament  presents 
upon  its  upper  surface  a  groove  or  canal  leading  directly  to  the  oviduct. 
The  number  and  delicacy  of  the  fimbrise  can  be  well  seen  by  taking  a 
fresh  specimen  of  the  oviduct  and  gently  moving  the  abdominal  end  to 
and  fro  in  clear  water.  From  the  opening  into  the  oviduct  a  number 
of  folds,  continuous  with  similar  formations  in  the  body  of  the  organ, 
radiate  to  the  circumference  of  the  pavilion. 

An  accessory  pavilion  is  found,  according  to  Sappey,  once  in  sixty 

1  Commonly  called  Fallopian  tubes.  Fallopius,  a  famous  anatomist  of  the  sixteenth  century 
the  successor  of  Vesalius  in  the  University  of  Padua,  describing  the  oviduct  compared  it  to  tuba,  & 
trumpet,  not  a  tube  or  canal ;  and  his  name  has  been  given  to  the  organ.  But  the  oviducts  were 
described  long  before  the  time  of  Vesalius  by  Erophilus,  and  then  by  Rufus  of  Ephesus.  It  seems, 
therefore,  that  it  would  be  better  to  have  the  names  of  these  organs  determined  by  their  most 
important  function,  that  of  excretory  ducts  for  the  ovaries,  than  to  perpetuate  one  which  is  doubly 
misleading. 


80 


PHYSIOLOGY  OF  PREGNANCY. 


subjects;  once  in  sixteen,  according  to  Richard.  In  some  instances  two 
have  been  observed,  aud  once  three.  They  have  the  same  form  as  the 
normal  one,  and  communicate  with  the  oviduct;  it  is  possible  that  the 
ovule  may  enter  one  of  these  from  the  oviduct,  and  thence  pass  into 
the  abdominal  cavity.  The  internal  or  uterine  orifice  of  the  oviduct  is 
only  one-twenty-sixth  of  an  inch,  or  one  millimetre,  in  diameter.  The 
oviduct  is  formed  of  three  coats,  an  external  peritoneal,  a  middle  mus- 
cular, and  an  internal  mucous.  The  peritoneal  coat  extends  from  the 
uterus  over  the  entire  length  of  the  organ,  but  of  course  fails  at  the 
lower  portion  corresponding  with  the  interval  between  the  folds  of  the 
broad  ligament.  The  muscular  coat  consists  of  a  layer  of  longitudinal 
fibres,  and  beneath  it  one  of  circular  fibres ;  both  of  these  are  continued 
into  the  muscular  walls  of  the  uterus.  The  mucous  membrane  is  thrown 

in  folds  which  are  closely  applied  to  each 
FlG-  46-  other,  so  that  there  may  result  a  capillary 

attraction,  similar  to  that  observed  when 
two  pieces  of  glass  are  pressed  together, 
and  then  partly  immersed  in  water.  The 
mucous  membrane  is  lined  with  ciliated 
epithelium,  the  movement  of  the  cilia 
being  from  the  ovary  to  the  uterus; 
this  condition  is  supposed  to  be  a  factor 
in  the  transmission  of  the  ovule  to  the 


uterus. 

J.  Bland  Sutton1  has  recently  shown 
that  the  mucous  membrane  of  the  ovi- 
ducts is  glandular ;  these  glands  are 
formed  by  infoldings  of  the  surface  epi- 
thelium, and  hence  are  very  simple  in 
character.  In  oviparous  vertebrates  the  glands  of  the  oviduct  secrete 
a  viscid  albumin  for  the  investment  of  the  ovum.  Sutton  adds  :  "  So 
far  as  the  human  ovum  is  concerned,  there  is  little  room  to  doubt  that 
the  viscid  albuminous  material  secreted  by  the  glands  of  the  Fallopian 
tube  serves  as  a  pabulum  for  the  embryo  in  its  early  stages,  absorption 
taking  place  by  means  of  the  chorionic  villi,  which,  standing  upon  the 
zona  pellucida,  are  immersed  in  a  highly  nutritive  bath  furnished  by 
these  glands." 

The  oviducts  have  the  same  source  of  blood  and  nerve  supply  as 
the  ovaries.  The  lymphatics  unite  with  those  of  the  uterus  and  of  the 
ovary. 

DEVELOPMENT  AND  SOME  OF  THE  ANOMALIES  OF  THE  FEMALE 
GENERATIVE  ORGANS.  While  naturally  belonging  to  the  subject  of 
Embryology,  it  is  thought  suitable  to  give  in  connection  with  the 
anatomy  of  the  female  organs  of  generation  a  brief  sketch  of  their 
development,  and  present  some  of  the  anomalies  of  obstetric  interest 
and  importance  that  may  occur  in  that  development. 

DEVELOPMENT  OF  THE  EXTERNAL  ORGANS  OF  GENERATION. 
The  formation  of  these  organs  begins  in  the  fourth  week  of  embryonic 


SECTION  OP  NORMAL  FALLOPIAN 
(After  BLAND  SUTTON.) 


1  London  Obstetrical  Society's  Transactions,  vol.  xxx.    London,  1889. 


THE  FEMALE  SEXUAL  ORGANS.  81 

life.  At  that  time1  there  is  at  the  posterior  extremity  of  the  body  a 
simple  opening,  representing  the  orifice  common  to  the  intestine  and 
the  allantois,  the  future  bladder,  into  which  the  Wolffian  canals  will 
also  empty,  and  which  is  the  orifice  of  the  cloaca — the  inferior  portion 
of  the  intestine  after  the  development  of  the  allantois  being  called  the 
cloaca.  Before  this  single  opening  is  divided  into  two,  anal  and  uro- 
genital,  there  appears  in  front  of  the  orifice  an  elevation  called  the 
genital  swelling  or  tubercle ;  then  two  lateral  folds,  the  genital  folds. 
At  the  end  of  the  second  month  this  swelling  is  greater,  and  there  is 
seen  at  its  lower  part  a  cleft  or  fissure,  extending  to  the  opening  of  the 
cloaca,  the  genital  furrow.  About  the  middle  of  the  third  mouth  the 
cloacal  opening  is  divided  so  as  to  form  two  orifices ;  the  most  generally 
received  explanation  of  this  division  is  that  it  occurs  by  the  formation 
of  two  lateral  folds  from  the  cloaca,  and  at  the  same  time  a  projection 
from  the  point  of  union  of  the  rectum  and  allantois  descends ;  the  lateral 
folds  and  the  central  process  unite  so  as  to  form  a  complete  wall,  the 
inferior  border  of  which  becomes  the  perineum,  and  the  wall  divides 
the  cloaca  into  two  cavities,  rectal  and  uro-geuital. 

The  labia  majora  are  developed  from  the  lateral  genital  folds,  and 
the  labia  minora  from  the  borders  of  the  genital  fissure,  while  the 
clitoris  is  formed  from  the  genital  tubercle,  or  the  upper  part  of  the 
genital  swelling.  Into  the  uro-genital  sinus  the  bladder  developed 
from  the  allantois  and  the  seminal  ducts  empty,  and  hence  its  name. 
This  sinus  is  shortened  by  the  descent  of  the  vagina,  and  in  the 
fourth  month  of  embryonic  life  the  urethra  and  vagina  are  distinct 
canals. 

DEVELOPMENT  OF  THE  INTERNAL  ORGANS  OF  GENERATION. 
The  internal  genital,  as  well  as  the  urinary,  apparatus  is  developed 
from  two  transitory  embryonic  structures  known  as  the  Wolffian  bodies. 
From  the  fact  that  these  bodies  temporarily  exercise  the  function  of  the 
kidneys  they  are  known  as  primitive  kidneys,  false  kidneys,  primordial 
kidneys,  and  kidneys  of  Oken.  Their  structure  is  analogous  to  that 
of  the  kidneys  :  they  are  composed  of  an  excretory  duct,  which  occu- 
pies a  longitudinal  position,  and  of  fine  tubes  which  are  transverse  and 
empty  into  this  duct ;  these  canaliculi  are  enlarged  at  their  closed  end, 
and  in  this  enlargement  a  vascular  glomerulus  is  found.  The  duct 
appears  prior  to  the  gland,  according  to  the  general  law2  in  the  forma- 
tion of  all  glandular  organs,  that  the  excretory  canal  is  first  formed. 
In  the  second  month  of  embryonic  life  the  Wolffian  body  appears  as 
an  oblong  mass  situated  on  the  side  of  the  vertebral  column,  and  extend- 
ing from  the  chest  to  the  pelvis.  These  bodies  soon  become  atrophied, 
leaving  as  their  chief  vestige  on  each  side  the  organ  of  Rosenmiiller,  or 
the  parovarium,  which  has  been  described  in  connection  with  the  descrip- 
tion of  the  broad  ligaments.  Before  this  atrophy  occurs  there  is  a 
notable  thickening  of  epithelium,  called  by  Waldeyer  germinative  epi- 
thelium, composed  of  long  cylindrical  cells  upon  the  inuer  and  upon  the 
outer  surface  of  the  Wolffian  body ;  the  former  is  the  origin  of  Miiller's 
duct,  the  latter  of  the  ovary  and  the  ovules.  The  formation  of  Miil- 
ler's duct  takes  place,  according  to  Waldeyer,  by  the  appearance  of  a 

1  Kolliker.  2  Imbert,  op.  cit. 


82 


PHYSIOLOGY  OF  PREGNANCY. 


FIG.  47. 


longitudinal  fold  of  the  germinative  epithelium  which  is  sunk  in  the  con- 
nective tissue  of  the  external  lateral  part  of  the  Wolffian  body  ;  this  fold 

is  covered  over  and  thus  converted  into  a 
tube.  It  remains  open  externally,  and 
that  portion  becomes  the  pavilion.  The 
occurrence  of  secondary  pavilions,  to  be 
referred  to  in  the  description  of  the  ovi- 
duct, is  readily  explained,  according  to 
Duval,  by  supposing  that  the  canal  of 
Miiller  is  not  completely  closed  in  all  its 
extent  at  the  period  of  embryonic  life 
when  the  two  borders  of  the  gutter,  which 
give  origin  to  it,  are  turned  toward  each 
other,  in  order  to  transform  the  gutter 
into  a  canal.  Miiller's  ducts  unite  in  a 
part  of  their  course  to  form  the  uterus 
and  the  vagina  ;  the  limit  to  this  union  is 
the  insertion  of  the  round  ligament,  which 
is  the  analogue  of  the  gubernaculum  testis 
in  the  male,  and  has  the  same  relations 
with  the  inguinal  canal.  All  of  the  duct 
below  the  round  ligament  unites  with  the 
corresponding  portion  of  the  duct  on  the 
other  side,  thus  making  at  first  a  double 
uterus  and  vagina  ;  but  absorption  of  the 
intervening  wall  occurs,  and  each  organ 
is  single.  The  left  duct  is  usually  fur- 
ther in  front  than  the  right,  and  the  two 
are  united  in  this  oblique  position ;  the 
presence  of  the  intestine  upon  the  left  side  is  thought  to  explain  the 
fact  that  the  left  duct  is  placed  further  to  the  front  than  the  right. 
The  fusion  of  the  two  ducts  is  complete  in  the  embryo  of  two  months. 
The  point  at  which  this  union  begins  is  unsettled.  Kolliker  believes 
that  it  is  at  the  middle  of  Miiller's  canals,  while  others  hold  that  it 
takes  place  from  below  upward.  All  that  portion  of  the  duct  above 
the  insertion  of  the  round  ligament  becomes  the  oviduct.  The  promi- 
nence on  the  internal  face  of  the  Wolffian  body  is  composed  of  a  mass 
of  embryonic  connective  tissue  covered  by  well-developed  germ  epithe- 
lium ;  it  is  the  first  rudiment  of  the  genital  gland,  and  is  found  alike 
in  the  embryo  which  is  to  be  a  male,  as  well  as  in  that  which  is  to  be  a 
female ;  in  the  female  the  ovaries  and  ovules  are  derived  from  the  epi- 
thelial covering,  while  the  outgrowth  itself  is  destined  to  furnish  the 
vascular  stroma  of  the  ovary. 

The  next  change  that  is  observed  is  the  appearance  of  cells,  which 
are  round,  have  a  well-developed  nucleus  and  distinct  nucleolus ;  these 
are  the  primordial  ovules  or  primitive  ova.  At  the  deep  part  of  the 
genital  eminence,  and  in  close  contact  with  it,  sections  show  that  the 
tubes  of  the  upper  portion  of  the  Wolffian  body  are  narrower  and  have 
a  clearer  epithelium  than  those  of  the  lower  portion ;  the  superior  is 
known  as  the  sexual  or  genital  portion,  the  inferior  as  the  urinary.  If 


DIAGRAMMATIC  OUTLINE  OF  THE 
WOLFFIAN  BODIES,  AND  THEIR  RE- 
LATION TO  THE  DUCTS  OF  MtiLLER 

AND    THE    REPRODUCTIVE    GLANDS. 
(From  ALLEN  THOMSON.) 

ol.  Seat  of  origin  of  ovary  or  testes. 
W.  Wolffian  body.  w.  Wolffian  duct. 
m.  Duct  of  MUller.  fire.  Genital  cord. 
ug.  Tiro-genital  sinus,  i.  Rectum,  cl. 
Cloaca. 


THE  FEMALE  SEXUAL  ORGANS. 


83 


the  genital  prominence  is  to  be  developed  into  a  testicle,  the  germinative 
epithelium  and  the  primordial  ovules  rapidly  disappear ;  but  if  it  is  to 


FJG.  48. 


HUMAN  OVULE,  AND  OVULES  OF  RABBIT,  PIGEON,  AND  ASCAKIS.  (High  power.) 
A.  Primordial  egg  (human)  from  a  fetus  at  the  eighth  month.  B.  Primordial  follicle  from  a 
rabbit;  C,  from  a  pigeon.  D.  A  somewhat  older  follicle  from  the  same  animal,  exhibiting  the 
commencement  of  the  formation  of  the  secondary  yolk.  E.  Csecal  extremity  of  the  ovary  of  the 
ascaris  nigrovenosa.  F.  An  egg  of  this  animal.  O.  An  egg  from  the  follicle  of  a  rabbit,  2  mm.  in 
diameter ;  a.  epithelium  of  the  ovum ;  b.  radially  striated  zona  pellucida ;  e..  germinal  vesicle  ;  d. 
germinal  spot ;  e.  yolk. 

FIG.  49. 


SCHEME  OF  THE  HOMOLOGY  OF  THE  INTERNAL  GENITAL 
ORGANS  OF  THE  MALE  (A.  RIGHT  SIDE)  AND  OF  THE  FEMALE 
(B.  LEFT  SIDE). 

O.  Ovary.  T.  Testicle.  W.  Canal  of  Wolfl ;  in  the  female 
it  atrophies ;  in  the  male  it  forms  the  deferent  canal. 
4The  genital  part  (1)  of  the  Wolfflan  body  is  represented 
in  the  male  by  the  epididymis,  in  the  female  by  the  body 
of  Rosenmtiller.  The  urinary  portion  (2)  forms  in  the 
male  the  paradidymis,  in  the  female  the  parovarium ;  it 
also  forms  in  the  male  the  vas  aberrans  (x).  M.  Canal  of 
Mtiller ;  it  disappears  in  the  male.  Its  free  extremity, 
which  forms  in  the  female  the  pavilion  (P),  forms  in  the 
male  the  hydatid  of  Morgagni  (h).  Its  inferior  extremity 
forms  in  the  female  the  uterus  and  the  vagina  (O)  and  in 
the  male  the  prostatic  utricle  (P). 


84  PHYSIOLOGY  OF  PREGNANCY. 

be  an  ovary,  the  former  becomes  more  developed  and  the  ovules  increase 
in  number.  The  primordial  ovules,  in  consequence  of  the  growth  of 
other  cells,  especially  of  those  of  the  mesoblast,  which  furnishes  the 
framework  of  the  ovary,  pass  from  their  superficial  position  into  the 
subjacent  layer ;  in  this  change  of  place  they  carry  with  them  ordinary 
epithelial  cells,  and  thus  each  ovule  is  furnished  with  an  envelope  which 
is  lined  with  epithelium,  and  so  the  ovisac  or  Graafian  vesicle  is  formed. 
According  to  Pfliiger,  however,  the  changes  are  as  follows :  the  pro- 
liferating germ  epithelium  sends  prolongations  into  the  forming  mass  of 
the  ovary — inversions  of  the  external  covering — and  thus  tubes  full  of 
cells,  and  which  become  separated  from  the  surface,  result.  Constric- 
tions occur  in  these  tubes,  and  the  portion  between  the  two  constricted 
parts,  each  bead  in  the  strand,  represents  a  Graafian  vesicle,  the  inver- 
sions of  the  external  covering,  at  first  tubular,  then  becoming  glandular 
cords. 

Dr.  Foulis,  from  his  investigations  as  to  the  development  and  structure  of  the 
ovary,  denies  the  presence  of  tubular  structures,  and  therefore  the  formation  of 
Graafian  vessels  as  given  by  Pfliiger.  His  statement  is  this  :l  All  the  ova  are 
derived  from  the  germ  epithelial  cells.  In  the  development  of  the  ovary  small 
and  large  groups  of  the  germ  epithelial  cells  become  gradually  imbedded  in  the 
ever-advancing  stroma.  Germ  epithelial  cells  do  not  grow  downward  into  the 
substance  of  the  ovary.  The  ovarian  stroma  constantly  grows  outward,  surround- 
ing and  imbedding  certain  of  the  germ  epithelial  cells.  As  these  latter  increase 
in  size,  and  as  the  stroma  thickens  around  them,  the  whole  ovary  becomes 

FIG.  50. 


I! 

UTERUS  UNICORNIS.    (From  SCHRODER.) 

LH.  Left  horn.    LT.  Left  tube.    Lo.  Left  ovary.    L  Lr.  Left  round  ligament.    RH.  Right  horn. 
RT.  Right  tube.    Ro.  Right  ovary.    R  Lr.  Right  round  ligament. 

enlarged.  Pfliiger's  tubes  in  the  kitten's  ovary  have  no  existence  as  such,  but 
are  appearances  produced  by  long  groups  of  imbedded  germ  epithelial  cells, 
many  of  which  groups  are  not  completely  cut  off  from  the  germ  epithelial  layer 
by  the  young  ovarian  stroma.  Such  growths  of  germ  epithelial  cells,  in  various 
forms,  are  met  with  in  all  ovaries,  but  have  no  importance  whatever  as  tubular 
structures.  No  real  tubular  structures  from  which  Graafian  follicles  are  formed 
exist  in  the  mammalian  ovary  at  any  stage  of  its  development. 

In  reference  to  the  general  development  of  the  internal  generative 
organs  there  is  in  embryonic  life  a  certain  period  of  sexual  indifference, 
a  period  when  the  substratum  for  the  evolution  of  a  male  or  a  female 

1  Transactions  of  the  Edinburgh,  Obstetrical  Society,  vol.  v.,  1879. 


THE  FEMALE  SEXUAL  ORGANS. 


85 


is  alike,  and  nature  gives  no  indication  of  her  purpose  as  to  which  shall 
be  produced.  In  tin's  connection  the  homologies  between  the  male  and 
female  internal  generative  organs  are  of  interest ;  these  homologies  are 
well  shown  in  Fig.  49,  from  Duval. 


FIG.  51. 


UTERUS  BICORNIS  DUPLEX.    (From  KUSSMAUL,  after  EISENMANN.) 

a.  Double  entrance  to  vagina,  b.  Meatus  urinarius.  c.  Clitoris,  d.  Urethra,  e,  e.  Double  vagina. 
/,/.  External  orifices  of  uterus,  g,  g.  Double  cervix,  h,  h.  Bodies  and  horns  of  uterus.  i,i.  Ovaries. 
k,  k.  Tubes.  I,  I.  Round  ligaments,  m,  m.  Broad  ligaments. 

Anomalies  of  development  of  the  external  sexual  organs  may  be  the 
cause  of  sterility,  but  chiefly  interest  the  obstetrician  in  regard  to  the 
determination  of  sex  in  some  cases  of  miscarriage,  or,  in  other  instances, 
in  which  labor  occurs  after  the  foetus  is  viable. 

At  three  months  the  clitoris  is  as  long  as  the  penis,  and  indeed  from 
the  relatively  greater  size  of  the  former  compared  with  other  organs  of 
the  vulva  in  the  early  months  of  intra-uterine  life  mistakes  as  to  the 

1  Winckel. 


86  PHYSIOLOGY  OF  PREGNANCY. 

sex  may  arise  if  a  thorough  examination  be  not  made.  At  birth,  too, 
if  there  be  congenital  hypertrophy  of  the  clitoris,  similar  error  may 
occur,  and  a  female  be  thought  a  male  infant.  The  difficulty1  is  increased 
if  not  only  the  clitoris  but  also  the  labia  majora  be  hypertrophied,  for 
with  the  hypertrophy  of  the  latter  organs  they  may  be  united  higher 
than  normal,  and  may  contain,  as  has  been  observed  in  some  cases,  the 
sexual  glands.  These  anomalies  may  not  only  lead  to  mistakes  as  to 
the  sex  in  some  cases,  but  in  others  to  the  assertion  of  hermaphroditism. 
Such  errors  were  much  more  frequent  in  ancient  than  in  modern  times, 
and  led  to  the  sacrifice  of  many  newborn,  for  the  supposed  union  of 
the  sexes  in  an  individual  was  regarded  as  so  monstrous  that  the 
Athenians  threw  into  the  sea,  the  Romans  into  the  Tiber,  all  infants 
who  were  thought  hermaphrodites.  In  most  cases  of  alleged  hermaph- 
roditism the  condition  is  apparent,  not  real,  and  arises  when  the  ex- 
ternal generative  organs  of  one  sex  very  closely  resemble  those  of  the 
other ;  it  is  called  female  hermaphroditism  if  this  condition  is  observed 
in  the  female. 

FIG.  52. 


»  DOUBLE  VAGINA  AND  UTERUS. 

Anomalies  of  the  uterus  and  vagina  are  in  most  cases  plainly  caused 
by  arrests  of  development.  Thus  in  case  of  duplicity  of  the  vagina 
the  process  of  development  was  arrested  after  the  union  of  that  portion 
of  Miiller's  ducts  from  which  this  organ  originates,  but  before  absorption 
of  the  intervening  wall.1  If  the  vagina  be  double,  usually  the  same  con- 
dition is  present  in  the  uterus.  In  some  cases  one  of  Miiller's  ducts 
atrophies,  but  the  other  is  developed,  and  a  one-horned  uterus  results. 
Miiller's  ducts  may  unite  below  the  insertion  of  the  round  ligaments, 
and  the  uterus  then  has  two  horns.  In  some  cases  the  fund  us  of  the 
uterus  is  not  developed,  but  the  surface  is  depressed,  and  the  organ  is 
said  to  be  heart-shaped,  or  cordiform.  The  dividing-wall  in  the  two 
parts  of  Miiller's  ducts  may  be  complete,  or  the  lower  part  absorbed ; 
in  the  one  case  the  condition  is  described  as  uterus  septus,  or  bipartitus, 

1  A  novel  explanation  of  duplicity  of  the  uterus  and  vagina  was  published  in  an  American 
medical  journal  a  few  years  since :  ' '  There  was  a  superabundance  of  formative  material  directed 
to  these  parts,  and  in  consequence  of  the  richness  of  the  vitalizing  substance  the  consequence  was 
the  formation  of  double  organs." 


THE  FEMALE  SEXUAL  ORGANS 


87 


and  in  the  other  as*semiseptus,  or  semipartitus.  None  of  these  anomalies 
prevents  pregnancy — even  plural  pregnancy  has  been  observed  in  the 
one-horned  uterus,  each  child  being  perfectly  developed  ;  a  foetus  may 
occupy  each  half  of  a  double  uterus,  and  normal  labor  occur  at  different 
times,  showing  that  the  conceptions  were  not  contemporaneous.  Preg- 


FIG.  53. 


BIFID  UTERUS. 


nancy  in  one  horn  of  a  uterus,  especially  if  there  be  but  a  single  horn, 
very  closely  simulates  an  extra-uterine  pregnancy,  and  doubtless  has  in 
many  cases  been  mistaken  for  it. 

Illustrations  of  some  of  these  anomalies  are  presented  in  Figs.  50-54. 


PARTITIONED  UTERUS. 


THE  MAMM.E.  During  the  first  period  of  life  external  to  the 
mother  the  young  of  the  class  of  animals  known  as  mammiferse  are 
nourished  by  the  secretion  from  certain  glands  of  the  mother  which  are 


88  PHYSIOLOGY  OF  PREGNANCY. 

called  mammae,  while  in  intra-uterine  life  they  were  nourished  by  her 
blood.  The  word  mamma  is  from  the  Greek  fid^a.  It  is  remarkable 
that  in  many  different  languages  almost  the  same  word  is  applied  to  an 
organ  so  essential  for  the  growth  and  development  of  the  infant,  and 
that  this  word  is  usually  the  one  first  spoken  by  the  child. 

The  mammae  are  usually  two  in  the  human  female ;  they  are  situated 
one  on  each  side  of  the  chest1  anteriorly,  between  two  layers  of  the 
superficial  fascia?  upon  the  pectoralis  major,  corresponding  with  the 
space  from  the  third  to  the  seventh  rib,  and  separated  from  each  other 
by  the  space  over  the  sternum ;  this  intervening  space  is  the  bosom. 
They  are  rudimentary  in  the  male,  and  are  also  rudimentary  in  the 
female  until  she  approaches  puberty,  when  they  notably  increase  in 
size,  but  only  attain  their  complete  development  under  the  stimulus  of 
pregnancy  followed  by  lactation.  The  probable  suggestion  has  been 
made  that  when  females  through  a  few  successive  generations  fail  to 
nurse  their  offspring  these  glands  become  permanently  lessened  in  size. 

In  many,  if  not  in  most  cases,  the  mammae  are  of  unequal  size  ; 
though  authorities  differ  as  to  which,  the  right  or  the  left,  is  larger ;  it 
is  probable  that  the  right  breast  is  the  larger  in  the  majority  of  cases. 
A  curious  observation  is  attributed  by  Ploss2  to  the  Israelite  physicians 
of  the  Talmud  :  The  daughters  of  the  wealthy  class  have  the  right 
breast  better  developed  than  the  left,  because  of  the  garment  worn  over 
the  right  shoulder;  while  the  daughters  of  the  poor  have  the  left  breast 
the  larger  in  consequence  of  using  the  left  arm  in  drawing  water  and 
in  carrying  their  younger  brothers  and  sisters. 

The  mamma}  are  usually  somewhat  hemispherical  in  form  ;  but  they 
may  be  pyriform  or  conical,  and  are  then  by  some  regarded  as  indicating 
a  more  abundant  secretion  of  milk.  The  volume  of  the  breasts  is  not 
in  direct  relation  with  the  vital  power  and  force  of  the  individual,  nor 
do  these  organs  if  large  necessarily  indicate  abundant  supply  of  milk ; 
in  some  women  of  delicate  organization  the  breasts  may  be  big ;  and, 
moreover,  the  great  size  in  an  individual  may  not  be  from  increase  of 
the  glandular  tissue,  but  from  an  abundant  deposit  of  fat. 

For  convenience  of  description  the  breast,  in  regard  to  its  surface, 
has  been  divided  into  three  zones.  One  of  these  zones,  the  peripheral, 
is  very  much  the  largest,  and  presents  a  smooth,  white  surface,  beneath 
which  the  veins  may  be  seen  ;  if  the  female  has  given  birth  to  a  child, 
it  is  not  uncommon  to  find  the  skin  marked  by  sh-ice,  linece  albicantes, 
similar  to  those  found  upon  the  abdominal  wall.  The  second  or  mid- 
dle zone  is  composed  of  the  areola.  The  color  of  the  areola  is  in 
striking  contrast  with  that  of  the  peripheral  portion  ;  it  is  a  pale  rose 
in  virgins,  but  becomes  dark  in  pregnancy  in  brunettes,  while  it  changes 
only  slightly  in  blondes  or  in  those  having  red  hair ;  the  pigmentation 
occurring  in  pregnancy  never  entirely  disappears.  The  areola  is  one  to 
two  inches,  or  2.5  to  5  centimetres,  in  diameter.  The  skin  of  the 
areola  contains  many  sebaceous  glands,  but  in  addition  to  these  there 

1  Plutarch,  De  Amore  Prolis,  thus  explains  the  position  of  the  mammae  in  women :  Itaque 
quidem  animalibus  yentrum  ubera  desinunt,  mulien  superne  ad  pectus  nascuntur,  ut  in  promptu 
sit  osculari,  amplectique  et  fovere  infantem ;  nimirum  quia  pariendi  et  alendi  finis  est  non  neces- 
sitas,  sed  amor. 

«  Op.  cit. 


THE  FEMALE  SEXUAL  ORGANS.  80 

are  from  twelve  to  twenty  papular  or  tubercle-like  projections,  some- 
times called  the  glands  or  tubercles  of  Montgomery,  though  it  would 
be  more  appropriate  to  give  them  the  name  of  tubercles  of  Morgagni, 
for  they  were  well  described  by  him  more  than  a  century  before  the 
great  Irish  obstetrician  wrote,  in  regard  to  the  nature  of  which  different 
views  are  held.  Milk  may  be  discharged  or  pressed  out  of  them  during 
lactation,  a  fact  which,  according  to  Sappey,  results  from  a  communi- 
cating galactophorous  duct,  arising  from  a  supplemental  lobule  of  the 
mammary  gland,  but  they  are  essentially  sebaceous  glands.  De  Sinety1 
and  Duval,  however,  assert  that  they  communicate  with  isolated  min- 
iature mammary  glands  ;  and  according  to  Depaul,  they  are  rudi- 
mentary nipples.  Whether  sebaceous  glands  or  nipples,  they  are  greatly 
enlarged  in  pregnancy,  thus  making  one  of  the  most  distinctive  mam- 
mary signs  of  pregnancy.  Beneath  the  skin  of  the  areola  concentric 
circles  of  muscular  tissue  are  found ;  these  circles,  widening  as  the 
periphery  of  the  subareolar  surface  is  approached,  there  cease  ;  contrary 
to  that  observed  in  the  peripheral  portion  of  the  breast,  there  is  no  layer 
of  fat  beneath  the  skin. 

The  third  or  central  zone  is  that  occupied  by  the  nipple.  This  rises 
from  the  centre  of  the  areola  at  a  point  corresponding  with  the  fourth 
intercostal  space;  it  is  conical  or  cylindrical,  rounded  at  the  summit,  and 
measures  nearly  half  an  inch,  or  twelve  to  thirteen  millimetres,  in  height 
and  nearly  a  third  less  in  thickness.  In  some  subjects,  however,  the 
nipple  is  retracted,  so  that  its  upper  surface  is  level  with  or  beneath  the 
surrounding  areola,  presenting  in  the  latter  case  a  depression  similar  to 
the  umbilicus.  The  surface  of  the  nipple  has  nearly  the  color  of  the 
areola,  and  presents  a  somewhat  rough  appearance  from  the  numerous 
thick-set  papillae  beneath,  and  in  these  papilla?,  according  to  de  Sine'ty, 
corpuscles  of  Meissner  are  found.  It  has  no  hair  follicles,  but  is  abund- 
antly supplied  with  sebaceous  glands ;  generally  a  pair  of  these  glands 
is  found  at  the  mouth  of  each  of  the  galactophorous  ducts  which  open 
at  the  summit  of  the  nipple ;  the  only  part  of  the  nipple  in  which 
these  glands  fail  is  at  its  junction  with  the  areola,  a  matter  of  some 
practical  importance  with  reference  to  the  occurrence  of  fissures  at  this 
point  during  lactation.  The  nipple  is  provided  with  both  transverse 
and  longitudinal  muscular  fibres ;  contraction  of  the  former  causes  the- 
lothism,2  or  projection  of  the  nipple,  from  0^,  nipple,  and  u6tu,  to  push, 
while  retraction  of  the  nipple  results  from  predominance  of  the  action 
of  the  longitudinal  fibres. 

Beneath  the  skin  of  the  peripheral  portion  a  layer  of  connective  and 
of  fatty  tissue  is  found  ;  it  becomes  thicker  at  the  external  circumference 
of  the  organ ;  the  skin  is  supplied  with  sudoriparous  and  sebaceous 
glands  and  hair  follicles.  The  mammary  gland  is  racemose,  and  is 
composed  of  fifteen  to  twenty  lobes — ten  to  twelve,  according  to  a  recent 
authority — these  being  separated  from  each  other  by  fibrous  and  fatty 
tissue ;  the  gland  mass  is  thicker  at  the  centre  than  at  the  circumfer- 

1  De  Sinety,  op.  cit.,  states  there  are  found  upon  the  region  of  the  areola,  besides  the  sudori- 
parous glands,  three  other  kinds  of  glands  :  simple  sebaceous  follicles,  sebaceous  glands  divided 
into  several  lobes,  and,  finally,  isolated  true  mammary  glands,  producing  colostrum  and  milk 
under  the  same  influences  as  the  chief  gland.    The  nature  of  these  accessory  mammary  glands  has 
been  well  established  by  Duval. 

2  Duval. 


90 


PHYSIOLOGY  OF  PREGNANCY. 


ence.  Each  lobe  is  formed  of  a  number  of  lobules,  aud  each  lobule,  in 
turn,  of  culs-de-sac,  or  acini.  The  structure1  of  an  aciuus  from  within 
out  is  as  follows :  First,  a  single  layer  of  cubic  cells  ;  second,  an  incom- 
plete sub-epithelial  endothelium  ;  third,  the  membrana  propria ;  fourth, 
connective  tissue  abounding  in  cellular  elements;  aud  fifth,  a  fibrous 
tissue  rich  in  elastic  fibres  and  very  poor  in  cells.  A  small  duct  passes 
from  each  acinus  to  unite  with  similar  ducts  from  other  acini,  and  by 
this  union  of  ducts  the  larger  duct  of  a  lobule  is  formed;  the  ducts  of 
the  lobules  of  each  lobe  in  their  turn  unite  to  form  the  excretory  canal 
of  that  lobe,  the  galactophorous  or  milk  duct.  The  ducts  thus  formed, 
and  equal  in  number  to  the  entire  number  of  lobes,  convey  the  milk  to 
the  upper  surface  of  the  nipple ;  at  the  level  of  the  areola  the  ducts 
undergo  a  fusiform  dilatation,  and  this  dilated  part  is  known  as  the  lac- 
tiferous sinus.  It  is  quite  exceptional  for  the  milk-ducts  to  auastomose 
with  each  other.  The  milk-ducts  are  lined  with  cylindrical  epithelium ; 
the  ducts  of  the  acini,  near  the  latter,  have  the  same  lining  as  that  of 
the  glandular  structure,  aud,  like  them,  secrete  milk. 


FIG.  55. 


FIG.  56. 


ACINUS  OF  THE  MAMMARY 
GLAND  OF  AN  ADULT  FEMALE 
DURING  LACTATION.  (From  DE 
SIN£TY.) 

a.  Epithelial  cells.  b.  Nu- 
cleus, c.  Nucleolus.  d.  Globules 
of  milk.  e.  Fibres  of  connective 
tissue.  /.  Cells  of  connective  tis- 
sue. Magnified  300  diameters. 


STRUCTURE  OF  THE  BREAST. 


The  blood  supply  of  the  breasts  is  by  the  internal  and  external 
mammary  and  intercostal  arteries ;  the  blood  is  returned  through  the 
internal  mammary  and  the  axillary  veins.  The  lymphatic  vessels  are 
very  numerous,  and,  as  described  by  Sappey,  form  two  planes.  The 
first,  or  continuous,  presents  a  very  delicate  network  beneath  the  areola 
and  the  nipple ;  the  second,  or  glandular,  is  deep-seated  and  is  peri- 
lobular ;  the  vessels  do  not  penetrate  into  the  lobules,  but  there  are 
numerous  lymph  spaces  in  the  connective  tissue  surrounding  these.  All 
the  trunks  from  the  deep  layer  of  lymphatics  are  directed  toward  the 
areola,  and  they  form  a  plexus  remarkable  for  the  size  of  the  vessels ; 


1  Duval. 


THE  FEMALE  SEXUAL  ORGANS.  91 

from  this  plexus  two,  in  some  cases  three,  trunks  pass  to  the  axillary 
ganglia.  The  lymphatics  of  the  skin  communicate  with  the  sub-areolar 
plexus.  The  nerves  come  from  the  fourth,  fifth,  and  sixth  intercostals, 
from  the  thoracic  branches  of  the  brachial  plexus,  and  from  the  snb- 
clavicular  branches  of  the  cervical  plexus.  According  to  W inkier,  the 
vasomotor  nerves  come  especially  from  the  brachial  plexus. 

DEVELOPMENT  AND  ANOMALIES  OF  THE  MAMMAE.  "  The  first 
indication  of  the  mammary  gland  is  seen  about  the  third  month  of  intra- 
uterine  life,  consisting  of  an  in-growth  of  cells  of  therete  mucosum,  sur- 
rounded by  the  fibrous  tissue  of  the  skin.  At  about  the  fifth  or  sixth 
month  the  rudimentary  ducts  of  the  lobules  are  apparent,  springing 
from  the  central  collection  of  cells."1  At  birth  the  lobes  are  distinct, 
and  the  milk-ducts  open  at  the  nipple.  A  painful  swelling  of  the 
breasts  is  sometimes  observed  in  the  newborn,  male  and  female ;  it  lasts 
four  or  five  days,  and  there  can  be  pressed  from  the  nipple  a  few  drops 
of  colorless  viscid  liquid,  and  finally  milk.2 

Polymastia  is  much  more  frequent  than  amastia.3  The  superfluous 
breasts  are  generally  found  in  the  axillae,  or  below  the  normal  ones,  but 
they  may  be  on  the  thighs,  on  the  back,  or  in  the  groins ;  more  rarely 
they  are  in  the  median  line,  but  when  here,  unlike  those  placed  in  other 
abnormal  positions,  they  do  not  secrete.  There  may  be  but  one  of  these 
supernumerary  organs,  more  frequently  there  are  two,  and  a  case  has 
been  reported  in  which  there  were  five. 

Absence  of  the  nipple  is  very  rare,  imperforation  less  so,  and  im- 
perfect development  not  at  all  uncommon.  Hypertrophy  of  the  nipple 
has  sometimes  been  seen ;  in  one  instance  this  organ  was  as  large  as  a 
pigeon's  egg.  Sometimes  the  increase  of  the  nipple  is  in  its  length  only ; 
but  even  then  it  may  be  impossible  for  the  infant  to  nurse.  Imperfect 
development  of  the  mammary  glands  is  not  infrequent,  and  examples 
of  primiparaB,  especially  of  those  American-born,  who  cannot  supply 
sufficient  milk  for  their  infants,  are  frequently  seen.  Many  of  these 
primipane  whose  secretion  of  milk  is  so  scanty  may  after  subsequent 
pregnancies  have  an  abundant  supply — a  tardy  development  of  the 
glands  occurring. 

1  Shakespeare  and  Simes  :  Cornil  and  Ranvier's  Pathological  Histology. 
8  Bouchut :  Traite  Pratique  des  Maladies  des  Nouveau-Nes. 
3  William  Sneddon,  M.D. :  Numerical  Anomalies  of  the  Breast. 


CHAPTER    III. 

PUBERTY — OVULATION — MENSTRUATION. 

PUBERTY  is  that  epoch  in  human  life  when  the  individual  first 
becomes  capable  of  reproduction.  It  occurs  about  two  years  earlier  in 
the  female  than  in  the  male,  and  the  physical1  and  psychical  changes 
characterizing  its  advent  are  more  marked  in  the  former  than  in  the 
latter.  The  girl's  pelvis  enlarges  and  her  breasts  notably  increase  in 
size  as  she  enters  this  period  of  life ;  the  one  change  indicates  prepara- 
tion for  childbirth,  the  other  provision  for  the  nourishment  of  the  new- 
born. The  external  genitals  are  developed,  and  hair  grows  upon  the 
mons  veneris  and  upon  the  labia  majora ;  the  circumference  of  the  neck 
is  greater,  and  the  voice  changes  ;  the  body  is  fuller  and  more  gracefully 
rounded ;  sharp,  irregular,  and  angular  outlines  are  replaced  by  sym- 
metrical curves,  and  new  beauty  of  form  and  of  general  expression  is 
manifested — it  is  the  springtime  of  female  life,  the  bud  unfolding  into 
the  flower.  The  girl  passing  into  womanhood  puts  away  childish  things, 
turning  from  frivolous  amusements,  from  the  toys  and  plays,  or  from 
rude  sports  in  which  she  has  found  pleasure ;  she  enters  a  new  life,  has 
new  thoughts,  desires,  and  emotions.  Hitherto  she  has  been  living 
solely  in  and  for  the  present ;  but  now  the  future  with  its  lights  and 
shadows,  its  hopes  and  fears,  makes  a  large  part  of  her  life.  She  is 
more  sensitive  and  reserved,  and  manifests  a  modest  dignity,  giving 
and  anticipating  respect ;  her  individuality  becomes  more  man  ifest,  her 
sense  of  duty  stronger,  and  her  ambition  greater. 

This  remarkable  transformation  is  the  expression  of  important 
changes  in  the  internal  generative  organs,  especially  in  the  ovaries,  for 
if  the  latter  be  absent  or  undeveloped,  the  distinctive  sexual  charac- 
teristics fail.  During  infancy  and  childhood  the  ovaries  slumbered  ; 
nature's  forces  were  busy  building2  up  the  individual,  and  it  is  only 
when  this  end  has  been  in  good  degree  attained  provision  is  made  for 
the  continuance  of  the  race.  The  ovaries  now  awaken  from  their  silent, 
inactive  state,  notably  increase  in  size,  and  enter  upon  the  discharge  of 
their  special  function  ;  they  determine  the  sexual  character,  and  for 
thirty  years  or  more  exercise  a  dominant  influence  upon  the  female 
organism ;  commonly  designated  as  uterine  appendages,  in  a  true  physi- 
ology the  uterus  ought  to  be  regarded  as  their  appendage.  The  function 
of  the  ovaries  is  the  maturing  and  rupture  of  ovisacs,  with  the  conse- 
quent escape  of  ovules  which  are  thus  offered  for  impregnation ;  this 
process  is  known  as  ovulatiou,  and  as  it  occurs  independently  of  sexual 
congress,  it  is  called  spontaneous  ovulation.  Until  recent  years  physi- 
ologists have  generally  held  that  ovulation  normally  occurs  at  regular 

1  See  Bland  Button's  work  contradicting  this.  *  Spiegelberg. 


.    PUBERTY—  OVULATION—  MENSTRUATION.  93 

periods,  but  many  now  maintain  that  this  is  not  true,  and  that  the 
ripening  and  rupture  of  ovisacs  go  on  independently  of  definite  times ; 
in  a  word,  that  ovulatiou  is  not  periodical. 

During  her  reproductive  life  the  human  female  has,  unless  pregnant 
or  nursing,  once  a  mouth  a  discharge  of  blood  from  the  uterus,  usually 
lasting  from  two  to  six  days.  This  discharge  is  frequently  called  the 
menses,  or  months,  and  during  it  the  subject  is  said  to  menstruate,  each 
term  pointing  to  the  periodicity  of  the  occurrence.  But,  as  will  be 
explained  hereafter,  menstruation  is  not  such  a  simple  process,  and  the 
external  flow  is  the  mere  sign  of  more  important  changes  occurring  in 
the  ovaries  and  uterus,  especially  in  the  latter. 

While  reproduction  is  possible  at  the  beginning  of  puberty,  science 
and  experience  alike  condemn  such  early  exercise  of  this  important 
power.  As  in  the  male,  premature  exercise  of  the  sexual  organs  is,  to 
use  the  words  of  Hufeland,  the  surest  means  of  inoculating  old  age,  so 
early  maternity  brings  increased  morbidity  and  mortality  to  the  female, 
while  her  offspring  will  be  less  well  developed,  have  less  vital  power, 
greater  liability  to  disease  and  to  early  death  than  they  would  have  had 
that  maternity  been  delayed  ;  the  general  law  of  both  animal  and  vege- 
table world  is  that  early  reproduction  gives  an  inferior  product. 
Woman's  form  is  not,  as  a  rule,  well  developed  before  she  is  twenty 
years  old  ;  her  pelvis,  which  has  been  called  the  laboratory  of  generation, 
has  not  attained  its  perfect  shape  until  then  ;  hence  an  early  maternity  is 
not  advisable.  Moreover,  she  lacks  the  mental  and  moral  growth  neces- 
sary for  the  grave  responsibilities  of  motherhood.  Modern  physiology 
and  large  experience  confirm  the  judgment  of  Plato,  the  wisest  of 
Greeks,  in  his  rule  that  "  A  woman  may  bear  children  to  the  State  at 
twenty  years  of  age."1 

The  physician,  whose  duty  is  not  only  to  heal  the  sick,  but  also  to 
prevent  disease  and  to  improve  the  race,  and  hence  who  must  be  a 
teacher  of  men  and  women, 
should  teach  sound  doctrine 
in  regard  to  the  injurious  re- 
sults of  precocious  marriage. 
Mothers  especially  ought  to 
be  taught,  though  some  have 
learned  the  lesson  by  their 
own  sad  experience,  that 
puberty  and  nubility  are  not 
equivalent  terms,  but  stand 
for  periods  of  life  usually 
separated  by  some  years ;  the  ^___^_- 

one   indicates    capability,  the  OVARY  WITH  RIPE  OVISAC. 

other  fitness  for  reproduction. 

OVULATION.  A  brief  statement  of  the  process  by  which  the  ovule 
is  liberated  from  the  ovisac,  and  its  following  migration  into  the  uterine 
cavity,  will  now  be  given.  The  ovigenous  layer  at  birth  forms  almost 
the  entire  ovary,  but  soon  after  the  bulbous  portion  begins  to  increase 

1  The  Republic. 


94  PHYSIOLOGY  OF  PREGNANCY. 

in  size,  while  the  former  remains  without  notable  change  in  bulk  until 
the  approach  of  puberty.  As  this  period  draws  near  several  of  the 
ovisacs  grow  rapidly  ;  one  of  them  becomes  prominent  by  its  great 
development ;  it  may  be  as  large  as  a  cherry,  and  forms  quite  a  pro- 
jection from  the  surface  of  the  ovary,  as  seen  in  Fig.  57. 

The  growth  of  the  ovisac  causes  increased  flow  of  blood  to  the  ovary  ; 
the  emergent  veins  of  the  bulb  having  larger  and  thinner  walls  than 
the  arteries  bringing  blood  to  it,  are  compressed  by  the  contraction  of 
the  muscular  tissue  they  traverse,  and  hence  an  increase  of  vascular 
tension  in  the  entire  organ,  including  not  only  the  bulb,  but  also  the 
ovisac.  The  contents  of  the  sac  augment,  and  its  walls  are  more  dis- 
tended ;  the  increased  fluid  in  the  ovisac  is  by  some  attributed  to  the 
breaking-down  of  part  of  the  cells  of  the  membrana  granulosa,  or  to  a 
secretion  of  fluid  by  them  ;  according  to  some,  an  intra-vesicular  hemor- 
rhage occurs,  in  many  cases  the  blood  forms  a  clot,  and  the  eifused 
blood  is  one  source  of  the  distention.  Rupture  of  the  ovisac  at  last 
takes  place,  caused  chiefly  by  distention,  but  also  by  fatty  degeneration 
of  the  wall  at  its  peripheric  pole.  An  assisting  cause,  according  to 
some,  is  muscular  contraction  of  the  ovary  which  has  been  depressed  at 
that  part  where  the  ovisac  was  growing,  and  which  under  the  stimulus 
of  increase  of  blood  tends  to  efface  that  depression,  thus  lifting  the 
ovisac  out  of  its  bed.  Rouget  believes  that  another  factor  in  causing 
rupture  is  the  action  of  the  contractile  coat  of  the  ovisac.  When  the 
sac  bursts  the  ovule  surrounded  by  the  proligerous  disk  escapes  and 
is  received  by  the  oviduct.  With  the  development  of  the  ovisac  there 
is  a  notable  increase  in  the  size  of  the  ovary ;  this  temporary  increase 
affects  chiefly  the  vertical  and  antero-posterior  measurements,  but  only 
slightly  the  longitudinal  measurement  of  the  organ. 

Various  explanations  have  been  given  of  the  transfer  of  the  ovule  to 
the  oviduct.  According  to  Rouget,  the  real,  the  only  possible  mechan- 
ism, is  that  which  depends  upon  the  fact  that  the  uterus,  the  ovaries, 
and  the  oviducts  are  formed  of  a  common  muscular  membrane,  and  by 
the  contraction  of  muscular  fasciculi  the  pavilion  is  applied  to  the  ovary 
so  as  to  receive  the  ovule.  In  some  of  the  inferior  animals  the  ovary 
and  oviduct  are  inclosed  in  a  common  capsule,  and  thus  escape  of  the 
ovule  into  the  abdominal  cavity  is  effectually  prevented.  In  the  bitch 
this  inclosing  capsule  has  a  narrow  slit,  but  in  the  bear  and  otter,  and 
in  some  other  animals,  it  is  entire.  This  formation  is  attributed  by 
Rouget  to  an  accident  of  evolution  which  has  become  permanent. 

Some  have  attributed  the  transfer  of  the  ovule  to  the  oviduct  to  the 
contraction  of  the  elastic  wall  of  the  ovisac.  A  less  improbable 
explanation  is  that  which  rests  upon  the  presence,  as  first  pointed  out 
by  Henle,  of  a  gutter  or  canal  upon  the  upper  surface  of  the  tubo- 
ovarian  ligament  through  which  the  ovule  passes  into  the  oviduct,  its 
progress  being  caused  by  the  movements  of  the  cilia  of  the  epithelium 
belonging  to  this  structure.  It  has  also  been  asserted  that  the  transfer 
is  effected  indirectly  by  the  movements  of  the  cilia  of  the  pavilion, 
causing  a  constant  current  to  the  oviducts  of  the  fluid  moistening  the 
peritoneum ;  the  presence  of  this  current  has  been  proved  by  the  fact 
that  color  ing- matter  introduced  into  the  peritoneal  cavity  of  animals  is 


PUBERTY—  OVULA  TION—MENSTR  UA  TION.  95 

afterward  found  in  the  oviducts  and  in  the  uterus.  Cases  of  what  is 
called  the  external  migration  of  the  ovule — that  is,  entrance  of  the 
ovule  into  the  oviduct  of  the  left  side,  for  example,  when  it  was  dis- 
charged from  the  right  ovary,  are  thus  explained;  the  vibratile  current 
of  the  oviduct  receiving  the  ovule  is  stronger  than  that  of  the  one 
nearest  which  it  is  when  the  ovisac  bursts. 

After  the  ovule  has  entered  the  oviduct  its  further  passage  to  the 
uterus  is  secured  by  the  movements  of  the  cilia  and  by  peristaltic  con- 
tractions of  the  oviduct. 

The  experiments  of  Bruzzi1  upon  rabbits  have  conclusively  proved 
that  external  migration  of  ovules  occurs;  thus,  for  example,  he  en- 
deavored, but  failed,  to  cause  extra-uterine  pregnancy  by  removing  the 
ovary  on  one  side  and  ligating  the  oviduct  of  the  other  ovary,  but 
copulation  was  followed  by  normal  pregnancy,  thus  proving  that  the 
ovules  coming  from  the  remaining  ovary  had  passed  through  the 
pervious  duct  of  the  opposite  side. 

The  ovisac — its  size  lessened  by  the  escape  of  the  ovule  and  its  sur- 
rounding granular  matter,  and  of  serous  fluid,  and  the  rent  through 
which  these  passed  closing — undergoes  certain  changes,  which  result  in 
its  obliteration,  the  most  notable  of  these  being  the  formation  of  the 
corpus  luteum  or  yellow  body.  As  observed  by  Raciborski,  the  term 
"  yellow,"  as  applied  to  these  bodies,  is  incorrect ;  for  while  true  of 
them  as  found  in  the  ovary  of  the  human  female,  yet  in  many  of  the 
inferior  animals  they  do  not  have  this  color ;  thus  in  the  cow  they  are 
deep  orange,  in  sows  a  whitish-gray,  etc.  Hence  he  proposed  as 
a  substitute  for  corpus  luteum  the  word  metoarion,  from  pera,  after, 
and  bapiov,  the  ovule,  and  some  have  adopted  it ;  but  corpus  luteum, 
with  its  plural  corpora  lutea,  is  in  such  general  use  by  obstetric 
authors  that  it  will  be  retained.  The  formation  of  the  corpus  luteum 
is  due  chiefly  to  hypertrophy  of  the  membrana  propria,  or  reticulata,  of 
the  ovisac ;  the  yellow  color  results  from  refracting  granulations2  more 
or  less  colored,  either  free  or  contained  in  cells ;  lymph  cells  are  also 
found  ;  the  endothelial  lining,  or  membrana  granulosa,  does  not  partici- 
pate in  the  formation  of  the  corpus  luteum.  Raciborski  asserts  that 
an  intra-vesicular  hemorrhage  occurs  prior  to  the  bursting  of  the  ovisac, 
while  Dalton's  investigations  have  led  him  to  conclude  that  the  hemor- 
rhage is  simultaneous  with  or  immediately  after  the  rupture;  still  others 
regard  the  hemorrhage  as  not  constant,  but  accidental  and  occasional, 
and  should  it  occur  the  process  of  the  formation  of  the  corpus  luteum  is 
hindered  rather  than  assisted.  Benckhiser,3  from  his  studies  of  the 
corpus  luteum  in  swine,  concluded  that  a  coagulum  was  an  inconstant 
and  unnecessary  condition  for  the  formation  of  this  body.  I  have 
examined  very  many  corpora  lutea  in  swine  and  in  sheep,  and  have 
never  yet  found  a  blood-clot  in  the  ruptured  ovisac. 

In  consequence  of  the  limited  space  offered,  the  membraua  propria 
from  its  hypertrophy  is  thrown  into  folds  like  the  cerebral  convolutions  ; 
these  folds  project  toward  the  cavity  of  the  ovisac,  and,  crowded  to  each 
other  from  opposite  sides,  meet  and  then  unite,  thus  obliterating  that 

1  Annales  de  Gynecologic,  Janvier,  1885.  2  De  Siuety. 

3  Archiv  fUr  Gynakologie,  1884. 


96 


PHYSIOLOGY  OF  PREGNANCY. 


cavity.     The  hypertrophy  does  uot  begin  until  after  the  ovisac  has 
burst,  and  hence  cannot  be  a  cause  of  that  event. 


FIG.  58. 


FIG.  59. 


Fig.  58.— GRAAFIAN  FOLLICLE  or  THE  HUMAN  OVARY  ;  RECENTLY  RUPTURED  DURING  MENSTRUA- 
TION, AND  FILLED  WITH  COAGULATED  BLOOD  ;  LONGITUDINAL  SECTION. 

a.  Tissue  of  the  ovary,  containing  unruptured  ovisacs.    b.  Vesicular  membrane  of  the  ruptured 

follicle,    c.  Point  of  rupture. 
Fig.  59. — HUMAN  OVARY  CUT  OPEN,  SHOWING  A  CORPUS  LUTEUM  DIVIDED  LONGITUDINALLY. 


FIG.  60. 


The   growth  of  the  corpus  luteum  reaches  its  maximum  in  thirty 
days  according  to  Dalton,  in  ten  according  to  Coste,  and  is  followed 

by  atrophy,  so  that  at  the  end  of  eight  or  nine 
weeks  there  remains  of  the  entire  mass  a  mere 
lamina  of  fibrous  tissue,  situated  just  beneath 
a  pit  or  depression  on  the  surface  of  the 
ovary,  marking  the  place  where  the  ovisac 
burst ;  according  to  Robin,  there  may  also  be 
found,  in  some  cases,  fat  globules,  or  free  fat, 
and  amorphous  or  crystalline  coloring-mat- 
ter. During  the  regression  of  the  corpora 
lutea  the  color  becomes  much  lighter — white, 
instead  of  yellow — so  that  they  are  sometimes 
called  corpora  albicantes. 

TRUE  AND  FALSE  CORPORA  LUTEA. 
Should  the  ovule  be  impregnated,  the  corpus 
luteum  reaches  a  larger  size  and  continues 
longer.  Hence  a  distinction  has  been  made 
between  the  corpus  luteum  of  menstrua- 
tion and  that  of  pregnancy,  the  one  being  called  false,  the  other  true. 
But  such  terms  are  misleading,  for  these  bodies,  though,  as  before  said, 
differing  in  size  and  duration,  are  essentially  the  same.  The  history  of 
the  corpus  luteum  of  menstruation  has  been  given.  The  corpus  luteum 
of  pregnancy  grows  for  thirty  or  forty  days  after  conception ;  it  then 
remains  stationary  until  the  end  of  the  fourth  month,  when  it  begins  to 
lessen,  so  that  at  the  end  of  nine  months  it  has  only  two-thirds  its  greatest 
size,  and  in  a  month  after  delivery  is  reduced  to  a  small,  indurated 
mass.  In  some  cases,  however,  the  growth  of  the  corpus  luteum  of 


HUMAN  OVARY:  SHOWING  A 
CORPUS  LUTEUM,  NINE  WEEKS 
AFTER  MENSTRUATION.  FROM  A 
GIRL  DEAD  OF  TUBERCULAR 
MENINGITIS. 


PUBERTY— 0  VULATION—MENSTE  UATION.  97 

pregnancy  may  continue  longer  than  has  been  indicated,  while  in  others 
the  regression  may  be  more  rapid  ;  there  is  no  absolute,  only  a  general 
rule  applicable  to  either. 


FIG.  61.  FIG.  62. 


CORPUS  LUTEUM  OF  PREGNANCY  AT  THE  END  CORPUS  LUTEUM  OF  PREGNANCY  AT  TERM. 

OF  FOURTH  MONTH.    FROM  A  WOMAN  DEAD  FROM  A  WOMAN  DEAD  IN  DELIVERY 

BY  POISON.  FROM  RUPTURE  OF  THE  UTERUS. 

MENSTRUATION.  This  is  a  temporary  and  intermittent  function  of 
the  female  organism,  and  has  as  its  most  obvious  phenomenon  a  dis- 
charge of  blood  from  the  genital  canal.  The  function  is  temporary,  for 
it  does  not  begin  until  puberty,  and  it  ceases  in  almost  all  cases  when 
the  reproductive  period  of  life  ends.  It  is  intermittent,  usually  recur- 
ring at  regular  periods  each  month,  but  also  presents  longer  intervals  of 
absence,  as  during  pregnancy  and  lactation. 

The  study  of  menstruation  includes  that  of  its  general  and  local 
phenomena,  the  character,  duration,  and  quantity  of  the  discharge,  and 
its  periodicity  ;  the  time  of  life  when  it  begins,  and  that  when  it  ceases  ; 
and  the  theories  which  have  been  proposed  explaining  its  occurrence, 
especially  in  its  connection  with  ovulatiou. 

The  general  phenomena  of  menstruation  are  chiefly  those  connected 
with  innervation  and  circulation.  The  reflex  sensibility  is  increased ; 
occasional  chilliness  and  flashes  of  heat,  neuralgic  pains  in  various  parts 
of  the  body  may  occur,  and  either  light  or  grave  manifestations  of 
hysteria ;  some  females  during  menstruation  are  drowsy,  and  few  are 
disposed  to  exercise  the  usual  activity  of  daily  life,  but  rather  seek  rest, 
if  not  seclusion ;  sensitiveness  to  moral  or  to  physical  impressions  is 
greater.  There  is  in  many  cases  congestion  or  irritation  of  various 
parts  or  organs  of  the  body  ;  the  breasts  may  be  swollen  and  painful ; 
there  may  be  sensations  of  fulness  and  throbbing  pain  in  the  head  ;  the 
face  is  flushed  in  many  cases,  a  dark  circle  is  about  the  eyes,  and  an 
eruption  may  occur  upon  the  skin ;  some  are  attacked  with  diarrhoea, 
many  with  irritability  of  the  bladder ;  the  thyroid  gland  is  larger,  and 
some  have  a  mild  tonsillitis. 

The  local  phenomena  are  those  connected  with  the  generative  organs. 


98 


PHYSIOLOGY  OF  PREGNANCY. 


The  external  organs  are  swollen  and  have  increased  sensibility ;  there 
is  a  feeling  of  fulness,  of  weight,  and  of  "  bearing-down"  in  the  pelvis, 

backache,  pain  or  increased  sensibility 
referred  to  the  iliac  fossae,  and  some  ful- 
ness or  meteorism  of  the  lower  part  of 
the  abdomen.  Few  women,  at  least 
among  the  civilized,  when  menstruating, 
are  entirely  exempt  from  physical  dis- 
comfort, so  that  the  expression,  "  being 
unwell,"  used  for  this  function  by 
many,  is  something  more  than  a  mere 
euphemism. 

Very  important  changes  occur  in  the 
internal  sexual  organs.  Increased  deter- 
mination of  blood  to  these  causes  con- 
gestion, and  in  some  a  temporary 
hypertrophy.  This  transitory  hyper- 
trophy is  especially  manifested  in  the 
ovaries  and  in  the  uterus.  The  latter 
organ  is  increased  in  size  one-fourth, 
one-third,  or  even  more ;  its  muscular 
fibres  present  a  reddish  appearance,  and 
they  are  swelled  and  less  firm.  The 
mucous  membrane,  in  consequence  of 
excessive  hyperaemia,  is  greatly  swelled 
and  thrown  into  folds,  "recalling  by 
its  anfractuosities  and  projections  the 
aspect  of  the  cerebral  convolutions ; " 
the  orifices  of  the  glands  are  more  dis- 
tinct, and  pour  out  an  abundant  secre- 
tion, which  is  the  prelude  to  the  san- 
guineous discharge.  The  vaginal  cervix 
is  swelled  and  softer,  and  presents  a 
deeper  hue  than  in  the  menstrual  in- 
terval ;  the  os  is  somewhat  open.  The 
mucous  membrane  of  the  vagina  pre- 
sents a  dark  red,  in  some  cases  a  violet 
color;  it  is  swelled,  and  there  is  a  slight 
elevation  in  its  temperature.  The  phenomena  of  congestion  and  in- 
creased secretory  activity  are  followed  by  hemorrhage. 

The  hemorrhage  results  from  the  hypersemia  being  so  great  that, 
according  to  some,  rupture  of  the  capillaries  of  the  mucous  membrane 
of  the  cavity  of  the  body  occurs.  Menstruation,  in  its  congestion  and 
discharge  of  blood,  has  been  called  a  diminutive  of  pregnancy,  while 
Baudelocque  called  it  a  periodical  abortion.  The  capillary  tension 
immediately  preceding  the  rupture  of  these  vessels  is  explained  by  con- 
traction of  the  muscular  fasciculi  inclosing  the  vessels  of  supply  and 
return,  this  contraction  affecting  the  veins  more  than  the  arteries,  in 
consequence  of  the  thin  walls  of  the  former,  and  by  contraction  of  the 
muscular  rings  surrounding  the  large  uterine  veins. 


SECTION  THROUGH  Mucous  MEMBRANE 
OP  THE  VIRGIN  WOMB.  (After  ENGEL- 

MANN.) 

S.  Mucous  membrane.  D,  Uterine 
glands  with  funnel-shaped  stria,  if. 
Muscular  stratum.  X  40. 


PUBERTY—  0  VULATION—MENSTR  UATION.  99 

While  rupture  of  the  capillaries  is  chiefly  due  to  their  great  disten- 
tiou,  fatty  degeneration  with  detachment  of  the  superficial  epithelial 
cells  is  held  by  some  to  facilitate  this  rupture. 

This  statement  is  according  to  Dr.  Engelmann's  researches.  Williams  asserts1 
that  the  entire  mucous  membrane  is  cast  off,  thus  leaving  the  muscular  surface 
bare,  and  that  a  new  mucous  membrane  is  produced  therefrom  ;  the  physiological 
objection  to  this  theory  is  apparent  and  seems  insuperable.  Leopold  states  that 
fatty  degeneration,  instead  of  preceding  and  in  any  degree  causing  the  menstrual 
hemorrhage,  occurs  during  its  progress.  Fritsch2  remarks  that  recently  strong 
arguments  have  been  adduced  against  these  views,  and  that  it  is  a  mistake  to 
attribute  the  hemorrhage  to  fatty  degeneration,  for  in  case  of  completely  intact 
mucous  membrane  diapedesis  occurs,  the  blood  transuding  from  the  vessels.  We 
therefore  return  to  the  old  theory  which  considered  the  hemorrhage  as  a  result  of 
the  greatly  swelled  and  distended  vessels.  Perhaps  the  arrangement  of  the 
vessels  in  the  mucous  membrane  is  important,  for,  according  to  Leopold,  more 
vessels  pass  to  than  come  from  it. 

Haller,  Hunter,  and  many  other  illustrious  physiologists  and  physicians  regarded 
the  menstrual  flow  as  a  secretion.  Among  American  medical  teachers,  both  the 
late  Dr.  Dewees  and  Dr.  Hodge  earnestly  upheld  this  view.  On  the  other  hand, 
the  late  Dr.  Charles  D.  Meigs3  treated  this  opinion  with  unsparing  ridicule,  ex- 
claiming :  ''  I  leave  it  to  the  student,  therefore,  to  settle  with  his  own  judgment 
the  question  how  can  blood-disks  be  the  subjects  of  secretory  action?  Can 
solids  be  secreted  ?  Could  not  a  woman  as  well  secrete  a  watch  or  a  diamond 
ring  as  one  single  blood-disk  ?" 

No  one  now  maintains  the  doctrine  that  the  menstrual  discharge  is  a  secretion, 
but  all  consider  it  a  hemorrhage,  though  different  explanations  are  given  of  its 
occurrence. 

CHARACTER,  DURATION,  AND  QUANTITY  OF  THE  MENSTRUAL  FLOW. 
At  the  beginning  of  the  monthly  flow  the  discharge  is  chiefly  serous  or 
mucous,  slightly  tinged  with  blood  ;  but  as  it  continues  the  number  of 
red  globules  increases  until  it  is  almost  pure  blood,  having  the  color  of 
that  which  escapes  from  a  vein,  though  Dewees  described  the  color  as 
resembling  that  of  mixed  arterial  and  venous  blood.  The  color,  how- 
ever, varies ;  thus,  it  may  be  very  light  and  the  fluid  almost  watery 
in  the  chlorotic,  and  excessively  dark  if  there  be  great  venous  conges- 
tion. The  odor  of  the  menstrual  fluid  has  been  compared  to  that  of  the 
marigold  ;  it  is  due,  in  most  cases,  to  long  retention  of  the  fluid  in  the 
uterus  or  in  the  vagina,  or  else  to  the  admixture  of  secretions  from  the 
genital  glands.  The  fluid  contains,  in  addition  to  red  globules,  white 
cells,  globules  of  mucus,  and  epithelial  cells  from  the  uterus  and  from 
the  vagina,  the  last  increasing  at  the  end  of  the  discharge.  It  is  alka- 
line, and  usually  does  not  coagulate ;  the  non-coagulation  is  generally 
attributed  to  the  intimate  mixture  of  the  secretion  of  the  uterine  glands 
with  it,  but  Delore  says  that  the  blood  flows  so  slowly  from  the  uterus 
that  it  is  in  part  defibrinated ;  however,  the  discharge  of  clots  is  fre- 
quently observed  if  the  flow  be  profuse,  and  in  some  cases  without  this 
condition  being  present. 

The  quantity  of  the  discharge  was  asserted  by  Hippocrates  to  be 
eighteen  ounces,  but  the  usual  estimate  is  four  to  six  ounces,  or  about 
128  to  192  grammes.  According  to  Tarnier,  if  the  flow  amounts  to 
500  grammes,  or  between  thirteen  and  fourteen  ounces,  there  is  menor- 

1  Obstetrical  Journal  of  Great  Britain  and  Ireland,  1875. 

2  Krankheiten  der  Frauen.  3  Obstetrics :  The  Science  and  Art. 


1 00  PHYSIOLOG  Y  OF  PREGNANCY. 

rhagia.  Sims  suggested  that  by  the  number  of  napkins  needed  in 
twenty-four  hours  the  quantity  could  be  determined,  in  a  normal 
menstruation  only  three  or  four  napkins  being  required  in  that  time. 

Many  have  regarded  climate  as  an  important  factor  in  determining 
the  duration  of  a  menstrual  flow  ;  among  recent  authorities,  for  example, 
both  Play  fair1  and  Harris2  refer  to  this  flow  as  being  more  profuse  in 
warm  climates ;  cold  climates,  on  the  other  hand,  have  been  thought  to 
lessen  the  flow.  This  belief  is  erroneous,  and,  according  to  Raciborski,3 
is  especially  founded  upon  the  old  theory  of  menstruation  which  re- 
garded it  as  resulting  from  plethora.  He  quotes  the  statistics  of  Faye, 
of  Christiana,  and  of  Peixoto,  of  Rio  Janeiro,  showing  that  the  men- 
strual epochs  and  the  quantity  of  the  flow  in  these  climates  present  the 
same  variations  which  are  met  in  central  Europe.  Saint  Vel,  whose 
observations  were  made  in  Martinique,  regarded  climate  as  without 
influence,  but  attributed  the  menorrhagia  from  which  European  women 
might  suffer  as  owing  to  the  anaemia  resulting  from  malarial  infection, 
and  thus  they  were  predisposed  to  increased  flow.  The  observations 
of  Hewau  upon  menstruation  in  women  upon  the  coast  of  Old  Calabar 
showed  that  the  flow  lasted  from  three  to  four  days ;  and  those  of 
Rochebrune4  in  regard  to  this  function  in  the  WolofF  negresses,  that  it 
lasted  only  three  days  and  was  slight. 

F.  Weber5  has  shown  that  at  St.  Petersburg  the  early  or  later  begin- 
ning of  menstruation  has  but  a  subordinate  influence  in  the  amount  of 
the  discharge;  but  he  attributes  an  important  r6le  to  the  bodily  consti- 
tution and  the  color  of  the  hair.  He  rejects  the  opinion  that  menstru- 
ation is  more  profuse  in  brunettes  than  in  other  women,  since  it  is  very 
often  abundant  in  blondes,  and  especially  in  women  with  red  hair. 

A  generous  diet  increases  the  flow,  while  it  is  lessened  by  scanty  and 
unsuitable  food.  Excessive  sexual  intercourse  may  cause  the  flow  to  be 
greater,  and  so,  too,  a  profound  mental  impression — though  in  most 
cases  this  arrests  it — may  for  the  time  have  such  an  effect.  Idiosyncrasy 
in  many  cases  has  an  important  influence,  and,  as  so  earnestly  asserted 
by  the  late  Dr.  Hodge,  every  woman  is  a  law  unto  herself  as  to  the 
quantity  of  the  monthly  discharge,  so  that  a  physiological  amount  in 
one  may  be  pathological  in  another.  The  best  criterion  of  a  normal 
flow  is  the  effect  upon  the  general  health;  if  that  be  not  injuriously  in- 
fluenced, the  flow  is  neither  too  great  nor  too  small. 

Hippocrates  declared  that  the  menstrual  blood  was  as  pure  as  that  of 
a  victim.  Nevertheless  this  just  opinion  has  not  been  held  by  primitive 
people ;  among  them  the  menstruating  woman  was  unclean,6  and  even 
one  of  the  most  learned  of  ancient  Romans,  Pliny,7  has  attributed  to 

1  System  of  Midwifery.  »  Notes  to  Playfair's  Midwifery. 

3  Traits  de  la  Menstruation.  *  Revue  d'Anthropologie,  1881. 

6  St.  Petersburger  med.  Wochenschrift,  1883. 

6  The  Mosaic  regulations  as  to  menstruation  are  well  known.    It  is  stated  by  Raciborski  and 
others  that  these  were  founded  upon  a  wise  hygiene,  since  the  investigations  of  Diday,  of  Lyons, 
have  proved  that  a  chronic  uretnritis  in  the  male  may  be  caused  by  coitus  during  menstruation  ; 
moreover  it  is  probable  that  the  menstrual  fluid  would  have  peculiarly  irritating  properties  in 
the  climate  of  Egypt.     Even  during  some  of  the  earlier  Christian  centuries  women  were  con- 
sidered unclean  while  menstruating,  and  not  allowed  to  partake  of  the  "  communion."     Ploss 
observes  (op.  cit.),  after  referring  to  the  general  belief  of  the  uncleanness  of  a  menstruating 
woman,  and  the  regulations  to  which  she  was  then  subjected:    "  VVe  find  such  rigid  rules,  in 
which  hygiene  and  religion  unite,  especially  in  the  Indo-German  race,  in  the  Indian,  as  well  as  in 
the  Semitic,  Jewish,  and  Arabian." 

7  He  asserted  that  at  the  approach  of  a  menstruating  woman  must  was  made  sour,  seeds  touched 
by  her  became  sterile,  garden  plants  are  from  like  cause  parched,  and  grafts  wither ;  the  fruit  falls 


P  UB  ER  TY—OV  ULA  TION—MENSTR  UA  TION.  1Q1 

the  monthly  discharge  such  serious  results  that  his  statements  are  amus- 
ing; from  their  absurdity. 

RECURRENCE  AND  DURATION  OF  THE  FLOW.  The  intervals  be- 
tween menstruations  are  not  the  same  for  all  women,  and  in  rare 
cases  only,  the  same  for  the  individual ;  variations  of  a  day  or  more 
are  frequently  observed,  the  flow  either  delaying  or  anticipating,  in 
most  women.  The  terms  menses,  catamenia,  "  monthlies,"  Monats- 
fluss,  etc.,  point  to  the  monthly  recurrence  of  this  function ;  so,  too, 
the  word  moons,  used  by  the  Chinese  for  this  flow,  has  similar  signifi- 
cance ;  it  also  points  to  the  old  belief  of  this  function  being  subject  to 
lunar  influence.  Goodman's  statistics  show  that  from  the  middle  of 
one  menstruation  to  the  middle  of  the  next  is  a  fraction  under  twenty- 
eight  days,  or  nearly  one  lunar  month.1  On  the  other  hand,  according 
to  Dubois  and  Courty,  the  typical  interval  is  a  solar  month  ;  this  is  also 
the  statement  of  Stoltz.  Deviations  from  this  interval  may  be  ob- 
served; thus,  one  woman  may  menstruate  every  three  weeks,  or  even 
more  frequently,  while  another  may  have  the  flow  only  once  in  six  or 
eight  weeks. 

The  duration  of  the  discharge  varies ;  usually  it  is  from  three  to  six 
days ;  it  is  probable  that,  as  stated  by  Hippocrates,  a  larger  proportion 
of  women  have  the  flow  three  than  any  other  number  of  days.  In 
some  the  discharge  lasts  but  one  or  two  days,  while  in  others  it  con- 
tinues eight  or  ten.  In  this,  too,  we  are  reminded  that  every  woman  is 
a  law  unto  herself. 

CAUSES  INFLUENCING  THE  FIRST  MENSTRUATION.  Climate.  In 
temperate  climates  girls  usually  begin  to  menstruate  when  from  thirteen 
to  fourteen  years  old ;  in  warm  climates  the  function  occurs  earlier,  in 
cold  later.  Raciborski2  states  that  a  year's  difference  in  puberty  cor- 
responds to  a  difference  of  eight  or  nine,  sometimes  of  only  four  degrees 
of  latitude  His  tables,  including  25,952  observations,  show  that  there 
is  a  difference  of  three  years,  ten  months  and  thirteen  days  between  the 
time  of  the  first  menstruation  of  girls  living  in  Central  Asia  and  that 
of  those  living  in  Lapland.  Krieger3  gives,  as  the  two  extremes,  eigh- 
teen years  in  Swedish  Lapland  and  ten  years  each  in  Egypt  and  in 
Sierra  Leone. 

Race.  The  daughters  of  English  residents  in  India  do  not  men- 
struate so  early  as  Hindoo  girls.  Negresses  born  under  the  burning 
sky  of  Africa  or  of  South  America  menstruate  early,  and  those  born 
in  Europe  are  equally  precocious.4  The  Jewish  race,  which  so  strik- 
ingly keeps  its  individuality  in  all  ages  and  places,  and  among  all  peo- 
ples, shows  in  regard  to  the  first  occurrence  of  menstruation  but  little 
difference  of  time,  no  matter  what  differences  of  latitude  are  compared. 

Residence.  Girls  living  in  cities  usually  menstruate  earlier  than 
those  living  in  the  country.  The  country  girl  has  a  simpler  diet, 

from  trees  beneath  which  she  sits,  her  glance  dims  the  brightness  of  mirrors,  blunts  the  edge  of  steel, 
and  removes  the  polish  from  ivory  ;  dogs  licking  the  discharge  are  seized  with  madness,  and  their 
bite  is  venomous  and  fatal. 

There  may  be  appended  to  this  terrible  invective  the  statement  that  one  of  the  fables  as  to  the 
death  of  Lucretius  is,  that  his  jealous  wife  compelled  him  to  drink  menstrual  blood,  and  madness 
with  death  followed.  Paracelsus  asserted  that  the  devil  made  of  this  discharge  spiders,  fleas,  cater- 
pillars, and  all  other  insects  that  infest  the  air  or  earth. 

1  Transactions  of  the  American  Gynecological  Society,  vol.  ii. 

•  Op.  cit.  3  Die  Menstruation.  4  Depaul. 


102  PHYSIOLOGY  OF  PREGNANCY. 

breathes  a  purer  air ;  she  has  regular  aud  abundant  time  for  sleep,  and 
is  much  less  exposed  to  special  causes  of  nervous  excitement  which  are 
so  prevalent  in  cities. 

Theatres,  dances,  novel-reading,  frequent  association  with  the  male 
sex  in  schools  or  in  society,  too  constant  or  improper  musical  culture, 
too  rich  and  stimulating  food,  witnessing,  if  not  at  times  participating 
in  fashionable  life,  are  among  the  factors  which  hasten  female  puberty 
in  cities.  It  has  been  stated  by  physiologists  that  girls  working  in 
factories  or  elsewhere,  constantly  associated  with  males,  have  in  many 
cases  precocious  menstruation.  On  the  other  hand,  there  are  many 
girls  in  our  large  cities  whose  puberty  is  delayed.  These  are  found 
among  the  very  pocr.  They  have  insufficient  food,  are  poorly  clothed 
and  housed,  denied  fresh  air  and  sufficient  rest,  and  compelled  to  toil 
beyond  their  strength ;  their  growth  is  checked,  their  bodies  stunted, 
and  hence  failure  in  the  vital  power  needed  for  sexual  development. 

Heredity.  This  influence,  independent  of  race,  is  observed  in  some 
cases.  Thus  a  mother  menstruates  early  or  late,  and  the  peculiarity  is 
transmitted  to  her  female  descendants. 

THE  GENITAL  SENSE.  The  genital  sense  has  been  defined  by  Raci- 
borski  as  the  greater  or  less  vigor  shown  in  the  development  of  ovisacs ; 
it  varies  greatly  in  individuals,  aud  has  an  important  influence  in  deter- 
mining the  time  of  the  first  menstruation.  In  some  cases  it  proves 
superior  to  the  influence  of  climate,  and  hence  there  may  be  precocious 
menstruation  in  cold,  and  delayed  menstruation  in  warm  climates.  It 
is  often  hereditary.  Precocious  menstruation  is  to  be  attributed  to  the 
great  power  of  the  genital  sense.  Some  years  ago  I  reported1  a  case  in 
which  menstruation  began  at  three  years  and  a  half,  and  continued 
regularly.  Ploss  has  collected  forty-five  instances  of  precocious  men- 
struation, the  oldest  of  the  subjects  being  in  her  eighth  year.  But  in 
some  of  these  girls  there  was  disease  of  the  ovaries,  in  others  hydro- 
cephalus,  and  in  still  others  rickets ;  nevertheless,  the  majority  were 
healthy.  In  some  instances  of  precocious  menstruation  precocious 
maternity  was  observed. 

Raciborski  has  given  the  name  of  emmenic  monstrosities  to  infants 
or  children  who  menstruated. 

Apathy  of  the  genital  sense  is  manifested  by  delayed  menstruation 2 
in  persons  whose  health  is  good.  This  delay  may  extend  to  four  or  five 
years,  or  even  a  longer  time,  beyond  the  period  when  menstruation 
usually  begins ;  in  some  cases  menstruation  did  not  occur  until  after 
one  or  more  pregnancies,  but  of  course  the  probability  of  conception 
prior  to  the  establishment  of  this  function  is  very  small. 

THE  MENOPAUSE.  The  menopause,  from  /«>,  month,  and  ™vaigt  ces- 
sation, is  the  end  of  the  menstrual  life.  It  is  influenced  by  various 
causes,  such  as  social  condition,  climate,  and  race;  aud  hence  presents 
as  great  differences  in  time  as  does  the  beginning  of  menstruation.  The 
menopause  occurs  somewhat  sooner  in  the  poor  than  in  the  rich,  prob- 

1  Cincinnati  Journal  of  Medicine,  1866. 

-  According  to  Villaret,  Joan  of  Arc  was  "  exempt  from  the  tribute  which  women  pay  the 
moon  ;"  and  he  suggests  that  this  exemption  was  due  to  her  high  destiny.  She  was  only  twenty 
years  old  when  executed,  so  that,  admitting  the  fact  of  her  amenorrhoea,  it  is  possible  there  was 
simply  delay  in  the  establishment  of  menstruation. 


P  UBERTY—  0  VULA  TION—MENSTR  UA  TION.  1Q3 

ably  earlier  in  cold  than  in  warm  climates,  and  also  in  the  black  races 
than  in  the  white.  Some  cease  to  menstruate  in  the  third  decade,  while 
in  others  the  function  is  continued  into  the  sixth  ;  thus  Courty  men- 
tions the  case  of  a  woman  who  still  menstruated  regularly  at  sixty-five 
years.  Charpentier  states  that  in  a  woman  under  his  observation  men- 
struation ceased  at  forty-eight,  but,  after  being  absent  for  twelve  years, 
returned,  and  continued  for  two  years,  the  recurrence  and  quantity 
being  normal. 

The  following  remarkable  case  was  recorded  by  the  most  eminent  of 
American  physicians,  Dr.  Rush  r1  "I  met  with  one  woman,  a  native  of 
Herefordshire,  in  England,  who  is  now  in  the  one-hundredth  year  of 
her  age,  who  had  a  child  at  sixty,  menstruated  till  eighty,  and  frequently 
suckled  two  of  her  children,  though  born  in  succession  to  each  other,  at 
the  same  time.  She  had  passed  the  greatest  part  of  her  life  over  a  wash- 
tub." 

Gibbon2  states  that  Asima,  the  mother  of  Abdallah,  when  she  was 
ninety  years  of  age,  upon  hearing  that  her  son  was  dead,  had  her  menses 
return.  Elsewhere  we  are  told  that  the  flow  was  fatal  in  five  days. 
Such  hemorrhage  and  at  so  advanced  an  age  would  not  be  regarded  by 
a  physician  as  menstruation. 

If  the  puberty  be  early,  the  menopuse  will  be  late,  while  on  the 
other  hand  delayed  puberty  indicates  early  cessation  of  the  monthly 
flow.  According  to  P6trequin's3  statistics,  one-eighth  of  women  cease  to 
menstruate  when  between  thirty-five  and  forty  years  of  age,  one-fourth 
from  forty  to  forty- five,  one- half  from  forty-five  to  fifty,  and  one-eighth 
from  fifty  to  fifty-five. 

The  obstetrician  should  remember  that  as  girls  have  conceived  before 
menstruating,  so  conception  has  occurred  mouths  and  even  years  after 
the  menopause. 

THEORIES  OP  MENSTRUATION.  CONNECTION  BETWEEN  MENSTRU- 
ATION AND  OVULATION.  Probably  the  earliest  theory  of  menstruation 
is  the  chemical,  or  that  which  holds  that  certain  materials  which  would 
otherwise  be  injurious  to  the  organism  are  eliminated  by  the  discharge. 
This  view  was  to  some  degree  expressed  by  pronouncing  a  woman  un- 
clean during  the  flow ;  even  to-day,  as  remarked  by  Fritsch,  the  expres- 
sion monatliche  Reinigung,  monthly  cleansing,  is  retained. 

In  recent  years  the  doctrine  has  to  a  slight  degree  found  a  scientific 
basis  in  this,  that  the  quantity  of  carbon  burned  by  man  increases  up 
to  thirty  years,  while  in  the  female  who  menstruates  it  remains  the  same, 
and  hence,  according  to  Aran,  menstruation  serves  to  eliminate  a  cer- 
tain amount  of  carbon  from  her  organism. 

Dr.  H.  Newell  Martin4  suggests  that  there  may  be  some  truth  in  a 
modification  of  the  purification  theory,  saying :  "One  important  function 
of  the  mucous  secretion  of  the  alimentary  canal  appears  to  be  that 
the  mucus  entangles  and  carries  on  with  it  to  the  rectum  indigestible 
and  other  possibly  harmful  solid  particles,  as  microbes.  The  uterus 
not  merely  cleanses  itself  by  secretion  and  expulsion  of  mucus,  which 

1  Medical  Inquiries  and  Observations,  1793,  Philadelphia. 

2  Decline  and  Fall  of  the  Roman  Empire. 

3  American  System  of  Obstetrics,  vol.  i.  4  Quoted  by  Tarnier. 


104  PHYSIOLOGY  OF  PREGNANCY. 

might  sweep  and  cleanse  its  lining  membrane,  but  discharges  during 
menstruation  all  the  superficial  parts  of  that  membrane.  We  know 
that  lying-in  women  are  especially  liable  to  be  infected  by  pathogenic 
bacterial  organisms;  and  in  the  earlier  stages  of  its  evolution,  when  the 
egg  is  still  segmenting  and  the  decidua  reflexa  forming,  it  may  well  be 
that  the  young  embryo  might  be  easily  infected  by  extraneous  organ- 
isms. This  view  gives  us  one  logical  meaning  for  menstruation.  It 
gives  us  a  reason  for  that  entire  casting  off  of  the  surface  layers  of  the 
mucous  lining  of  the  womb  which  occurs  each  month.  Menstruation 
breaks  down  and  discharges  all  the  old  mucous  membrane,  and  gets  rid 
of  bacteria  which  may  have  entered  through  the  os  and  found  a  suitable 
nidus  for  development.  Hence,  in  a  modified  form,  the  purification 
doctrine  is  still  tenable  as  giving  a  physiological  reason  for  menstrua- 
tion." 

This  ingenious  hypothesis  is  open  to  two  objections.  All  observers 
do  not  teach  the  breaking  down  and  discharge  of  "the  old  mucous 
membrane  "  as  a  phenomenon  of  menstruation,  and  according  to  some 
of  the  best  it  does  not  occur ;  the  presence  of  pathogenic  microbes,  or 
microbes  of  any  sort,  in  the  healthy  uterine  cavity  has  not  been  proved, 
but  disproved. 

The  theory  that  the  flow  results  from  plethora  is  one  of  the  oldest 
and  most  generally  adopted.  As  the  woman  had  to  nourish  the  unborn 
babe  she  was  supposed  to  be  endowed  with  superior  blood-making 
power.  But  if  she  did  not  conceive,  a  superfluous  quantity  of  blood 
was  made,  and  nature  brought  the  entire  amount  in  her  body  to  the 
normal  level  by  periodical  hemorrhages  from  the  womb. 

Some  made  the  function  peculiar  to  civilized  women.  Thus  Roussel 
asserted  that  in  the  primitive  or  savage  state  women  were  exempt  from 
menstruation ;  hard  work  and  simple  fare  prevented  them  from  being 
plethoric,  and  hence  no  hemorrhage  occurred,  as  it  was  not  needed ;  but 
it  was  necessary  in  the  case  of  civilized  women,  because  they  had  less 
exercise  and  more  abundant  and  better  food. 

Auber  also  denied  that  menstruation  occurred  in  savage  women,  and 
asserted  that  it  happened  in  the  civilized  because  of  failure  to  gratify 
the  reproductive  instinct,  and  thus  became  a  habit.1  Some  recent  writers, 
too,  have  sought  to  establish  the  pathological  character  of  menstruation  ; 
in  other  words,  menstruation  is  a  disease  which  impregnation  would 
prevent.  For  the  moment,  admitting  that  Auber's  theory  is  correct,  that 
is,  menstruation  occurs  from  failure  to  satisfy  the  reproductive  instinct, 
it  has  been  suggested  that  a  girl  might  be  impregnated  prior  to  men- 
struation, and  then  as  soon  as  possible  after  her  delivery  let  her  be  again 
impregnated,  and  thus  through  her  entire  reproductive  life.  At  the  end 
of  that  life  she  would  have  given  birth  to  thirty  or  forty  children,  and 
if  her  example  were  to  be  generally  followed,  society  would  demand  a 
new  proclamation  of  Malthusianism.  It  is  hardly  necessary  to  state 
that  menstruation  occurs  in  savage  women,  and  there  is  not  the  slightest 

1  Dr.  Gill  Wylie,  of  New  York,  has  recently  given  (American  System  of  Gynecology)  a  quasi- 
indorsement  to  the  civilization  theory  of  menstruation :  "  Although  the  generative  organs  are 
essential  to  reproduction,  they  are  not  essential  to  the  individual,  and  are  not  necessarily  used. 
Therefore,  menstruation  may  be  intended  to  take  the  place  of  the  free  exercise  of  the  function  of 
these  organs,  and  thus  compensate  for  the  restraint  and  disuse  so  much  and  so  necessarily  prac- 
tised by  civilized  races." 


P  UBERTY—O  VULA  TION—MENSTR  UA  TION.  1 05 

probability  that  at  any  period  in  the  history  of  the  race  in  any  land 
women  ever  lived  who,  as  a  rule,  became  mothers  without  being  subject 
to  menstruation.  It  has  been  suggested  that  the  menstrual  hemorrhage 
is  for  the  purpose  of  relieving  a  local  plethora,  that  of  the  sexual  organs, 
especially  of  the  uterus,  hypertrophy  of  its  mucous  membrane  with  con- 
sequent formation  of  a  deciduous  membrane  being  thus  prevented. 

Pfliiger  regards  the  uterine  hemorrhage  as  a  preparation  for  the 
attachment  of  the  fructified  ovum  to  the  uterus.  Menstruation,  accord- 
ing to  him,  is  the  inoculation  wound  of  nature  for  the  fastening  of  the 
impregnated  ovule  to  the  maternal  organism. 

I)r.  John  Goodman  has  advanced  the  theory  that  menstruation  is 
dependent  upon  a  law  of  monthly  periodicity.  This  law  is  the  resultant 
and  exponent  of  recurring  cycles  of  physiological  acts ;  these  monthly 
cycles  are  supposed  to  depend  upon  the  ganglionic  nervous  system.  But, 
as  remarked  by  de  Sin6ty,  to  attribute  the  flow  to  the  nervous  system 
explains  nothing. 

Passing  from  these  theories,  which  have  little  more  than  mere  histor- 
ical interest,  we  turn  to  that  which  is  founded  upon  ovulation,  and  which, 
though  different  explanations  of  the  relations  between  the  two  phenomena 
may  be  held,  meets  with  general  professional  acceptance.  The  view  that 
has  hitherto  been  commonly  received,  and  is  still  held  by  many,  is  that 
ovulation  is  periodical,  the  growth  and  rupture  of  an  ovisac  correspond- 
ing with  each  menstruation.  As  the  ovisac  grows  it  presses  upon  ovarian 
nerves,  and  by  reflex  irritation  causes  congestion  of  the  internal  genera- 
tive organs,  especially  of  the  uterus :  the  uterine  hypersemia  results  in 
hemorrhage  from  its  mucous  surface.  Here  the  question  arises  as  to 
whether  this  hemorrhage  is  facilitated  by  desquamation  of  the  superficial 
epithelium,  resulting  from  fatty  degeneration,  complete  casting-oif  of  the 
mucous  membrane  being  rejected.  According  to  some,  this  superficial 
desquamation  does  not  occur  until  the  close  of  menstruation,  and  there- 
fore has  nothing  to  do  with  the  hemorrhage.  Again,  excellent  author- 
ities state  that  they  have  failed  to  find  the  proof  of  elimination  of  the 
superficial  portion  of  the  mucous  membrane  in  menstruation.  De  Sin6ty, 
in  examining  the  discharge  during  the  monthly  flow,  could  not  discover 
the  least  fragment  of  mucous  membrane  or  of  epithelium ;  so,  too,  in 
women  dying  while  menstruating,  he  found  the  uterine  mucous  mem- 
brane entire  in  all  its  extent.  WinckeP  says :  "  Since  Huge  and  Moericke 
have  found  that  during  menstruation  the  ciliated  epithelium  of  the  uterine 
mucous  membrane  remains  intact,  an  observation  which  we  have  re- 
peatedly confirmed,  the  earlier  view  that  during  menstruation  a  fatty 
degeneration  of  the  superficial  layers  was  a  cause  of  menstruation  is 
incorrect." 

Admitting  these  statements,  the  necessary  conclusion  is,  that  the 
hemorrhage  in  menstruation  occurs  without  destruction  of  any  part  of 
the  uterine  mucous  membrane,  and  that  the  blood  escapes  from  the 
superficial  vessels,  not  by  their  rupture,  but  by  diapedesis  and  through 
an  intact  mucous  membrane. 

The  periodicity  of  menstruation  can  be  most  readily  explained  by 
attributing  it  to  the  ripening  of  an  ovisac,  for  this,  like  other  processes 

1  Lehrbuch  der  Frauenkrankheiten,  1886. 


106  PHYSIOLOGY  OF  PREGNANCY. 

of  growth,  would  naturally  be  supposed  to  require  a  certain  time. 
Again,  this  interpretation  of  the  connection  between  ovulation  and 
menstruation  corresponds  with  what  we  know  of  ovulation  and  "rut" 
or  "heat"  in  animals,  which  is  the  analogue  of  menstruation.  Nature's 
legislation  is  general  rather  than  special,  and  it  is  not  probable  she  would 
make  one  law  relating  to  reproduction  for  animals  in  general,  and  then 
a  special  law  for  human  beings. 

But  without  pressing  this  point,  let  us  see  the  proofs  that  are  adduced 
to  show  that  ovulation  is  not  periodical.  The  results  of  Leopold's  iu-> 
vestigations  are  thus  given  by  Foektistow:1  Fully  developed  follicles, 
those  already  ruptured,  and  fresh  corpora  lutea  may  be  found  at  any 
time  during  the  inter-menstrual  period.  These  may  not  be  present  dur- 
ing menstruation.  Hence  ovulation  occurs  without  menstruation,  and 
menstruation  may  occur  without  simultaneous  rupture  of  the  follicles. 
Ovulation,  therefore,  is  independent  of  menstruation,  and  is  not  period- 
ical. Nevertheless,  while  Leopold  denies  the  dependence  of  menstruation 
upon  periodic  ovulation,  he  does  make  it  depend  upon  the  ovaries,  and 
he  regards  its  periodicity  as  placing  it  in  the  category  of  rhythmical 
manifestations,  e.  g.,  the  pulse,  respiration,  or  ejaculation  of  semen. 

The  uterine  hypersemia  results  as  a  reflex  from  the  ovaries  caused,  not 
by  the  ripening  of  an  ovisac,  but  by  the  continued  growth  of  several. 
Foektistow,  in  answer  to  the  question  Avhy  does  not  menstruation  occur 
more  frequently,  gives  these  reasons  :  Comparatively  slight  ovarian 
irritation  is  not  sufficient  to  cause  a  reflex  so  soon.  The  essential,  too, 
of  the  menstrual  process,  is  that  anemia  follows  hypersemia,  and  irri- 
tability ceases.  Equilibrium  is  restored,  and  to  cause  another  reflex 
another  sum  of  irritations  is  necessary,  and  these  cannot  occur  at  once. 
The  changes  in  the  uterine  epithelium  which  began  with  the  hypersemia 
pass  away  with  the  following  ansemia,  and  the  epithelium  returns  to  its 
normal  condition,  a  process  which  continues  through  more  than  one-half 
of  the  inter-menstrual  period. 

Another  theory  of  menstruation  which  is  founded  upon  ovulation  is 
that  of  Lowenthal.2  According  to  him,  the  ovule  reaches  the  uterus 
before  impregnation ;  if  it  be  impregnated,  menstruation  does  not  occur  ; 
but  if  it  is  not  impregnated,  it  excites  a  uterine  congestion  which  ends 
in  hemorrhage.  Winckel3  observes  the  Achilles  heel  of  this  bold  hy- 
pothesis is  that  the  death  of  the  ovule  can  cause  active  congestion  of 
the  uterus.  Further,  this  hypothesis  is  a  revival  of  an  old  one ;  that  is, 
menstruation  results  from  the  failure  of  impregnation,  and  is  entitled  to 
no  more  credence  in  its  new  that  it  was  in  its  old  form. 

Auvard*  holds  that  the  menstrual  function  is  composed  essentially  of 
two  phenomena,  ovulation  and  genital  hemorrhage ;  these  two  phe- 
nomena are  independent  of  each  other,  but  dependent  upon  the  same 
cause,  this  cause  being  unknown,  and  resulting  from  the  constitution  of 
the  organism  :  in  a  physiological  state  they  are  associated,  and  on  the 
contrary  frequently  dissociated  in  a  pathological  condition.  He  asserts 

1  Archiv  fur  Gynakologie,  Band  xxvii. 

2  Archiv  fur  Gynakologie,  1885.  8  Op.  cit. 

*  Travaux  d'Obst6trique,  tome  premier,  Paris,  1889.  This  hypothesis  fails  in  adding  to  knowledge. 
It  is  no  more  satisfactory  than  Avicenna's  explanation  of  the  cause  of  labor  coming  on  :  "  At  the 
end  of  nine  months  labor  occurs  by  the  grace  of  God,"  or  that  of  one  of  Moltere's  characters  in 
regard  to  the  action  of  opium :  opium  causes  sleep  by  its  sleep-producing  properties. 


PUBERTY— 0  VULATION— MENSTRUATION.  107 

further,  that  a  genital  flow  simulating  the  discharge  is  not  menstruation 
if  ovulatiou  is  absent,  any  more  than  is  ovulation  without  hemorrhage. 

It  may  be,  as  stated  by  de  Siuety,  that  any  positive  theory  of  menstru- 
ation is,  with  our  present  knowledge,  premature  ;  nevertheless  it  must 
be  admitted  that  this  function  is  connected  with  the  ovaries,  for  if  these 
organs  are  congenital ly  absent,  or  if  they  are  undeveloped,  menstruation 
does  not  occur.  So,  too,  after  double  ovariotomy  menstruation  ceases. 
The  exceptions  to  this  rule  cannot  be  admitted  until  a  careful  post- 
mortem examination  has  proved  that  no  fragment  of  ovarian  tissue  has 
been  left  behind  in  the  lower  portion  of  the  pedicle,  as  has  happened  in 
some  cases.  Women  have  borne  children  after  both  ovaries  were 
believed  to  have  been  removed.  Olshauseu  performed,  as  he  thought, 
ovariotomy,  but  the  result  being  fatal  he  found  at  the  autopsy  that 
neither  ovary  had  been  removed.  Further,  even  if  both  ovaries  have 
been  completely  removed,  possibly  there  may  remain  a  supernumerary 
ovary,  a  condition  that  Beigel's  and  Winckel's  examinations1  prove  to 
be  far  less  rare  than  has  been  thought.  Until  in  those  cases  of  alleged 
perfectly  normal  menstruation2  post-mortem  examinations  prove  the 
entire  absence  of  all  ovarian  tissue,  either  a  fragment  of  an  organ  that 
has  been  removed  or  a  supernumerary  ovary,  the  doctrine  that  menstru- 
ation depends  upon  ovarian  action  will  remain.  So,  too,  it  is  in  the 
highest  degree  probable  that  there  is  an  intimate  connection  between 
ovulation  and  menstruation.  At  the  same  time  it  must  be  admitted 
that  the  two  may.be  distinct,  the  one  occurring  without  the  other, 
though  they  are  usually  associated.  Thus  there  may  be  occasional 
monthly  hemorrhages  without  ovulation,  or  the  latter  may  occur  without 
the  former.  Ovulation  may  begin  before  the  first  monthly  flow,  and 
impregnation  take  place ;  during  lactation  it  may  occur  without  men- 
struation, and  it  may  happen,  too,  after  the  menopause  ;  thus  there  is  an 
explanation  of  the  comparatively  frequent  instances  of  impregnation  of 
women  while  nursing ;  and  of  rarer  cases  in  which  this  event  has  oc- 
curred after  menstrual  life  has  ceased.  Further,  there  is  reason,  from 
what  has  been  observed  in  the  rabbit,  for  believing  that  coition  may 
cause  rupture  of  an  ovisac,  and  hence  ovulation  occur  independently  of 
menstruation. 

Ribemout-Dessaignes  and  Lepage3  conclude  that  there  is  no  good 
reason  for  not  admitting,  according  to  the  classic  theory,  (1)  that  ovula- 
tion has  its  external  sign  in  menstruation ;  (2)  the  escape  of  the  ovule 
from  the  ovisac  usually  occurs  at  the  end  of  a  monthly  flow,  and  gener- 
ally this  is  the  one  that  is  fecundated. 

1  Beigel  found  in  500  sections  supernumerary  ovaries  23  times.  Winckel  from  his  own  examina- 
tions concluded  they  were  present  in  3.6  per  cent.  Nevertheless,  Sutton  asserts,  Surgical  Diseases 
of  the  Ovaries  and  Fallopian  Tubes  :  "  So  far  as  the  evidence  at  present  stands,  an  accessory  ovary, 
quite  separate  from  the  main  gland,  so  as  to  form  a  distinct  organ,  has  yet  to  be  described  by  a  com- 
petent observer."  But  those  who  know  Professor  Winckel's  ability  and  his  thoroughness  of  inves- 
tigation will  doubt  the  error  attributed  to  him  in  this  quotation. 

*  Foektistow.  3  Precis  Obstetrique,  1893. 


CHAPTEK  IY. 

CONCEPTION — EARLY   DEVELOPMENT   OF   THE   IMPREGNATED   OVULE 
— FORMATION  OF  DECIDUOUS  MEMBRANES — FCETAL  APPENDAGES. 

CONCEPTION,  from  concipio,  means  in  metaphysics  a  grasping  into 
one,  and  in  physiology  the  uniting  of  two  living  elements,  one  male,  the 
other  female,  from  which  a  new  being  is  evolved.  Fecundation,  im- 
pregnation, and  by  some  incarnation  are  also  used  as  synonyms. 

A  woman  who  has  conceived  is  pregnant ;  pregnancy  begins  with 
conception  and  ends  with  labor.  The  pregnancy  is  single  or  simple  if 
only  one  ovule  has  been  fecundated,  but  plural  if  two  or  more  have 
been.  It  is  normal  when  the  uterine  cavity  contains  the  fecundated 
ovule  or  ovules,  and  abnormal,  ectopic,  extra-uterine  should  it  or  they 
be  external  to  that  cavity.  But  whether  the  pregnancy  be  single  or 
plural,  whether  normal  or  abnormal,  its  beginning  is  the  same. 

Human  conception  was  a  subject  of  great  interest  to  students  of 
nature,  whether  physicians  or  philosophers,1  in  ancient  times  ;2  numerous, 
and  many  of  them  very  curious,  hypotheses  were  proposed  in  explaining 
it,  and  indeed  it  is  only  in  comparatively  a  recent  period  that,  guided 
by  the  discoveries  of  the  microscope,  the  initial  step  in  reproduction  has 
been  placed  upon  a  scientific  basis. 

Aristotle  compared  the  menstrual  blood  to  a  block  of  marble,  while 
the  seminal  fluid  was  the  sculptor,  and  the  foetus  the  statue.  Galen, 
who  from  his  dissections  had  some  knowledge  of  the  ovaries,  and  gave 
them,  as  has  been  previously  stated,  the  name  testes  muliebres,  held  that 
they  furnished  a  secretion  which  in  the  womb  combined  with  the  sem- 
inal secretion  of  the  male  to  form  the  new  being.  For  many  centuries 
these  two  opinions  alternately  prevailed,  now  one,  and  again  the  other, 
receiving  the  more  general  acceptance.  But  they  were  alike  rejected  by 
the  recognition  of  Harvey's  aphorism,  omne  vivum  ex  ovo.  This  illus- 
trious physician  maintained  that  reproduction  in  all  animals  was  by  a 
female  element  analogous  to  the  egg  of  the  hen.  But  in  explaining  the 
way  in  which  development  of  the  egg  was  effected  he  accepted  the 
hypothesis  of  a  seminal  aura  ;  fecundation  occurred  in  like  manner  to 
the  action  of  a  magnet  upon  iron— contact  with  the  former  caused  the 
latter  to  have  magnetic  virtue ;  again,  he  illustrated  physical  by  mental 
conception — the  uterus  conceives  the  foetus,  as  the  brain  ideas  that  are 
formed  in  it. 

Confirmation  of  Harvey's  views  as  to  the  essential  element  in  human 

1  "  A  man  deposits  seed  in  a  womb,  and  goes  away,  and  then  another  cause  takes  it  and  labors 
on  it,  and  makes  a  child.   What  a  thing  from  such  a  material !"— Meditations  of  Marcus  Aurelius 
Antoninus. 

2  "  Drelincourt,  an  author  of  the  last  century,  brought  together  as  many  as  two  hundred  and 
sixty-two  groundless  hypotheses  concerning  generation  from  the  writings  of  his  predecessors  ;  and 
nothing  is  more  certain,  quaintly  remarks  Blumenbach,  than  that  Drelincourt's  own  theory  formed 
the  two  hundred  and  sixty-third."    (Allen  Thomson.) 


CONCEPTION.  109 

generation  was  for  a  time  given  by  de  Graaf  s  discovery  of  the  ovisacs, 
which  were  believed  to  be  human  eggs,  and  at  first  were  known  as  ova 
Grraafiana.  But  about  1677,  Ludwig  Hamm,  of  Dantzic,  examining 
with  a  microscope  the  discharge  occurring  in  the  nocturnal  emission  of 
a  patient  suffering  with  gonorrhoea,  discovered  living  spermatozoids. 
He  made  known  the  fact  to  the  great  microscopist,  Leeuweuhoek,  who 
also  saw  them ;  the  latter  soon  after  found  them  in  the  seminal  dis- 
charges of  healthy  men,  of  the  dog,  of  the  cat,  and  of  the  rabbit. 
Leeuwenhoek  concluded  from  his  observations  that  man  was  not  pro- 
duced— ex  ovis  imaginariis,  se,d  ex  animalculis  vivis  seu  vermiculis  in 
semine  virili  contentis.  He  asserted  :  Sperma  humanum  parvulis  puerulis 
esse  plenum.  The  supposed  animalcula?  received  the  name  of  sperma- 
tozoa, the  plural  of  spermatozoon  ;  but  as  these  terms  indicate  that  the 
objects  are  independent  existences,  a  view  now  held  by  only  few,  it  is 
better  that  they  should  be  replaced  by  spermatozoid  and  spermatozoids. 

Leeuwenhoek  believed  that  the  spermatozoids  had  sexual  character, 
and  some  observers  went  so  far  as  to  describe  their  sexual  organs.  Of 
course,  the  Harveian  theory  of  reproduction  was  for  the  time  rejected  ; 
and  this  process  was  simply  the  development  of  one  of  these  homunculi 
in  the  uterus,  the  female  merely  furnishing  a  nidus  for  that  develop- 
ment.1 But  the  progress  of  science  has  vindicated  the  truth  of  Harvey's 
theory  as  to  the  origin  of  the  human  being  and  of  all  animal  life  ;  it, 
however,  gives  no  support  to  the  hypothesis  of  a  seminal  aura,  which 
acting  upon  the  ovum  causes  its  development.  We  now  know  that  there 
must  be  an  actual  combination  of  the  male  and  the  female  element  in 
order  that  fecundation  can  occur. 

THE  SEMINAL,  FLUID.  The  semen,  when  ejaculated,  presents  an  ap- 
pearance somewhat  like  that  of  thin,  recently  boiled  starch  ;  it  is  alka- 
line and  mucilaginous,  and  has  an  odor  which  is  called  spermatic,  and 
has  been  compared  to  that  of  hemp  flowers  or  of  horn  filings.  The 
odor,  according  to  Robin,  does  not  belong  either  to  the  spermatic  or  to 
any  other  of  the  secretions  that  combine  with  it  during  the  ejaculation, 
but  is  developed  by  the  mixture.  Its  specific  gravity  is  somewhat 
greater  than  that  of  water  ;  it  is  not  coagulated  by  acetic  acid  or  by 
heat,  and  does  not  contain  albumin  ;  but  the  substance  found  in  it  which 
has  been  by  some  given  this  name  is  spermatine ;  after  it  has  become 
dry  it  presents  upon  the  stiffened  linen  where -it  has  been  deposited 
yellowish-gray  stains ;  the  quantity  discharged  at  a  single  ejaculation 
varies  from  fifteen  grains  to  two  drachms,  one  to  eight  grammes. 
Chemical  analysis  shows  the  presence  of  ninety  per  cent,  of  water,  six 
of  extractive  matters,  three  of  lime  phosphates  and  muriates,  and  one  of 
soda.  In  the  sperm  of  the  bull,  Kolliker  found  820  parts  of  water, 
151  parts  represented  by  spermatozoids,  26  by  salts,  and  21  by  fat  con- 
taining lecithine.  In  the  sperm  of  some  men  there  may  be  an  excess 
of  spermatozoids  with  a  deficiency  of  water — all  fish  and  no  water,  as 
Pajot  has  said — and  sterility  be  the  consequence.  With  the  microscope 
there -are  seen  cylindrical  cells,  pavement  epithelium,  leucocytes,  fine 

1  The  argument  used  in  "  The  Furies  "  for  the  acquittal  of  Orestes  for  the  murder  of  his  mother 
would  have  been  still  stronger  had  the  Greek  poet  Known  this  view — for  then  indeed,  as  asserted 
in  the  successful  defence  of  the  matricide,  the  mother  was  only  the  nurse,  and  the  father  the 
true  parent ,  and  mythology  tells  us  that  Minerva  had  no  mother,  only  a  father. 


110 


PHYSIOLOGY  OF  PREGNANCY. 


FIG.  64. 


granular  matter,  crystals  of  lime  phosphate,  and  the  essential  element, 
the  fertilizing  agents,  spermatozoids. 

SPERM ATOZOIDS.  The  form  and  size  of  spermatozoids  vary  in  dif- 
ferent animals,  but  there  is  no  relation  between  the  size  of  the  sperrua- 
tozoid  and  that  of  the  animal  from  which  it  comes ;  thus  the  spermato- 
zoid  of  the  elephant  is  no  larger  than  that  of  man,  while  that  of  the  rat 
is  five  times  as  large.  Waldeyer1  states  that  the  diversity  of  size  and 
form  of  spermatozoids  is  astonishing,  and  that  he  does  not  know  a  single 
instance  in  which  the  spermatozoids  of  different  animals  are  entirely 
similar,  and  he  believes  that  their  form  may  be  advantageously  used  to 
determine  their  species. 

The  spermatozoid  is  composed  of  a  head,  of  a  tail,  and  of  an  inter- 
mediate segment,  the  last  being  thus  designated  by  some,  but  by  others 
called  the  body.  The  entire  length  of  the  human  spermatozoid  is  not 

more  than  -5-^5-  to  -g-^-  of  an  inch,  or  one- 
twentieth  to  one-twenty-fifth  of  a  milli- 
metre. The  head  is  pyriform,  or  ovoidal, 
the  larger  end  being  attached  to  the  body 
or  intermediate  segment,  while  the  smaller 
end  is  free.  The  head  is  about  one- 
twrentieth  the  length  of  the  tail,  and  is 
quite  or  nearly  twice  as  long  as  it  is 
broad.  The  body,  intermediate  segment, 
or  beginning  of  the  tail,  is  only  -nnj-f  o"ff 
to  looHo-g-  of  an  inch,  or  one-three-hun- 
dredth to  one-four-hundredth  of  a  milli- 
metre ;  it  is  oval  and  flattened,  giving  it 
somewhat  the  shape  of  an  almond.  The 
tail,  or  caudal  filament,  is  thick  at  its  origin,  then  gradually  diminishes 
until  its  extremity  is  so  fine  as  not  to  be  visible  even  with  the  best 
magnifying  glasses.  One  of  the  most  striking  characteristics  of  sperma- 
tozoids is  the  power  of  executing  quick  and  rapid  movements ;  these 
movements  are  especially  rapid  immediately  after  ejaculation  ;  a  sperma- 
tozoid moves  a  distance  equal  to  its  length  in  one  second,  and  it  was 
stated  by  the  late  Dr.  Marion  Sims  that  spermatozoids  pass  from  the 
hymen  to  the  neck  of  the  womb  in  three  hours.  Lott  states  that 
spermatozoids  in  a  minute  move  3.6  mm.,  and  Wiuckel  adds  that  at 
this  rate  they  might  easily  pass  into  the  oviducts  in  a  few  minutes. 
The  head  is  the  part  which  always  advances  first ;  the  movements  have 
been  compared  to  that  of  an  eel  swimming  in  water ;  the  tail  may  be 
curved  in  a  circle,  but  very  quickly  becomes  straight  again,  and  its 
simple  undulatory  movements,  which  cause  progression  of  the  sperma- 
tozoid, are  resumed;  in  its  progress  over  the  field  of  the  microscope,  it 
may  sometimes  be  seen  quickly  pushing  out  of  its  way  epithelial  cells  or 
crystals  ten  times  its  size.2  The  movements  gradually  lessen,  then  there 
is  no  progression,  but  mere  oscillations  are  seen,  and  finally  all  motion 
ceases ;  but  by  warming  the  slide,  if  it  has  become  cold,  or  by  adding 
a  little  warm  water,  slightly  alkaline,  if  the  liquid  has  become  thick, 


SPERMATOZOIDS. 


Arch.  f.  mikrosk.  Anat,  August,  1888. 


2  Robin. 


CONCEPTION.  HI 

movements  are  resumed.  In  avoiding  these  two  causes  of  death  to  the 
spermatozoids  when  the  seminal  fluid  is  placed  between  two  glass  slides, 
the  movements  may  last  for  twelve,  twenty-four,  or  even  thirty  hours. 

Spermatozoids  have  been  found  alive  in  men  who  were  executed 
seventy  and  even  eighty-two  hours  after  death ;  in  the  bull  six  days 
after  it  was  killed  ;  in  the  oviducts  of  bitches  and  rabbits  seven  to  eight 
days  ;  in  the  cow  six  days  after  copulation  ;  in  the  human  female  they 
were  found  endowed  with  active  movements  in  the  cervical  canal,  by 
Hausmann,  seven  days  and  a  half,  and  by  Percy  eight  days  after 
coition.  In  the  female  bat  they  retain  their  fecundating  power  for 
many  months,  and  in  the  queen  bee  for  more  than  three  years.  The 
spermatozoids  of  a  frog  may  be  frozen  four  times  in  succession  without 
killing  them.  They  will  live  for  seventy  days  when  placed  in  the 
abdominal  cavity  of  another  frog.  (Mantegazza.)  Acid  solutions  kill 
spermatozoids  very  quickly,  and,  on  the  other  hand,  weak  alkaline 
solutions  quicken  or  awaken  their  movements  ;  cold  water  arrests  their 
movements,  and  corrosive  sublimate,  one  part  to  ten  thousand  of  water, 
is  destructive  to  spermatozoids,  while  they  seem  insusceptible  to  the 
action  of  poisons  of  organic  origin.1  The  normal  secretion  of  the 
uterus,  as  well  as  the  menstrual  discharge,  is  favorable  to  their  move- 
ments. In  the  examination  for  spermatozoids  a  magnifying  power  of 
three  hundred  diameters  is  sufficient,  but  in  medico-legal  investigations 
one  of  five  hundred  is  necessary. 

In  temperate  climates  boys  of  twelve  years  may  have  a  discharge 
simulating  the  seminal  fluid,  but  it  is  unusual  for  spermatozoids  to  be 
found  in  these  discharges  before  the  age  of  fifteen  or  sixteen  years.2 
The  reproductive  power  begins  somewhat  earlier  in  woman  than  in 
man,  but  it  lasts  much  longer  io  the  latter;  Lieg6ois,  from  his  investi- 
gations, concluded  that  about  one-half  of  men  between  sixty  and  eighty 
years  of  age  were  capable  of  fecundation.3 

Men  who  are  addicted  to  sexual  excess  may  have  seminal  discharges 
without  any  spermatozoids  being  present;  so,  too,  spermatozoids  may  be 
absent  in  the  case  of  some  men  who  are  in  good  health  ;  thus  Pajot 
found  this  condition  in  six  of  eighteen  husbands  whose  marriages  were 
sterile,  and  the  late  S.  W.  Gross  stated,  as  an  approximate  estimate,  that 
in  one  case  in  six  of  sterility  the  husband  is  at  fault. 

Recent  authors  greatly  increase  the  number  of  cases  in  which  the 
sterility  depends  upon  the  male;  35  per  cent.,  Kehrer;  40  per  cent., 
Lier  and  Ascher ;  and  even  57  according  to  Noeggerath.  (See  TraitS 
pratique  de  Gynecologic,  by  Bonnet  and  Petit,  1894.) 

As  has  been  previously  said,  the  animalcular  character  once  given  to 
spermatozoids  is  now  generally  denied.  The  arguments  against  this 
view  are  :  they  have  neither  organs  of  digestion  nor  of  reproduction  ; 
they  are  anatomical  unities  which  have  their  genesis  from  embryonic 
male  cells  or  spermatoblasts,  but  they  do  not  produce  such  cells ;  they 

1  Duval. 

2  In  the  light  of  the  statement  above  made  as  to  the  time  spermatozoids  are  first  found,  the 
story  of  Cato  being  a  father  at  eight  years,  as  well  as  that  said  to  have  been  told  by  St.  Jerome,  of 
a  boy  ten  years  old,  who,  sleeping  with  his  nurse,  impregnated  her,  is  to  be  rejected. 

3  The  illustrious  Corvisart  was  skeptical  as  to  the  prolonged  power  of  propagation,  for  when  the 
First  Napoleon  asked  him  if  a  man  at  sixty  could  be  a  father,  he  replied,  "  Sometimes."    "  And  at 
seventy  ?  "  then  asked  the  emperor.    "  Always,  sire." 


112  PHYSIOLOG  Y  OF  PREGNANCY. 

indicate  a  finality,  not  a  progress ;  they  are  regarded  as  similar  to 
ciliated  epithelium. 

In  order  that  fecundation  can  occur  there  must  be  an  actual  union 
between  the  male  element  and  the  female — between  the  spermatozoid 
and  the  ovule.  In  some  animals  external  fecundation  occurs,  the  eggs 
being  fertilized  after  they  have  been  expelled  from  the  female ;  or,  as 
in  the  frog  and  crab,  while  they  are  being  discharged.  But  in  human 
beings,  as  in  most  animals,  fecundation  is  internal.  The  place  of  union, 
between  the  spermatozoid  and  the  ovule,  was  supposed  to  be  the  uterine 
cavity,  and  this  opinion  is  maintained  by  some  eminent  authorities, 
among  whom  may  be  mentioned  Mayrhofer,  Wyder,  and  Lawson  Tait. 
But  this  opinion  is  generally  rejected,  because  it  does  not  explain  the 
occurrence  of  ectopic  pregnancy,  and  because  the  spermatozoids  are 
found  in  the  inferior  animals  to  have  entered  the  oviducts  and  advanced 
to  the  pavilions.  Moreover,  it  is  known  that  in  some  animals  the  ovule 
in  its  progress  through  the  oviduct  receives  a  covering  of  albumin1 
which  is  impenetrable  by  spermatozoids,  and  also  that,  unimpregnated, 
it  is  affected  during  this  progress  by  degenerative  changes  which  render 
impregnation  impossible.  It  is  therefore  now  generally  held  that  fecun- 
dation takes  place  in  the  external  third  of  the  oviduct,  possibly  near  or 
in  the  pavilion. 

ASCENSION  OF  THE  SPERMATOZOIDS.  Four  causes  have  been  in- 
voked to  explain  the  passing  of  spermatozoids,  deposited  in  vast2  num- 
bers in  the  posterior  vaginal  cul-de-sac  at  the  end  of  coition,  from  this 
point  into  the  external  portion  of  the  oviduct,  supposing  this  to  be  the 
usual  seat  of  fecundation.  Three  of  these,  that  of  capillary  force, 
of  aspiration,  or  intraction  by  the  uterus,  and  of  the  movements  of  the 
cilia,  make  these  bodies  merely  passive — they  do  not  ascend,  but  are 
transferred  or  translated.  But  it  seems  probable  that  the  spermatozoids 
would  not  have  been  endowed  with  such  force  and  rapidity  of  move- 
ment unless  for  the  accomplishment  of  an  important  purpose,  and  there- 
fore we  recognize  the  inherent  power  of  motion  on  their  part  as  the 
chief,  usually  the  only,  cause  of  their  being  in  the  oviducts.  Intraction 
on  the  part  of  the  uterus  is  impossible  in  certain  structural  diseases  of 
the  cervix,  and  is  powerless  when  the  seminal  discharge  has  been  from 
necessity  or  from  precaution  made  upon  the  external  sexual  organs,  and 
yet  in  each  condition  impregnation  has  been  known  to  occur.  Ciliated 
action  would  assist  the  spermatozoids  once  in  the  uterus  to  ascend  to 
the  oviducts,  but  the  action  of  the  cilia  of  the  latter  would  oppose  their 
further  progress.  It  may  be  that  Nature,  rich  in  resources,  does  not 
limit  herself  to  a  single  cause  in  securing  this  important  step  in  the 
continuance  of  the  race,  but,  while  having  a  chief  one,  at  times  has  this 
assisted  by  others. 

In  all  cases  more  or  less  time  intervenes  between  coition  and  conception, 
between  insemination  and  impregnation  ;  this  interval  possibly  is  some 

1  This  argument  is  strengthened  by  Bland  Button's  discovery  of  glands  in  the  oviduct,  these 
glands  secreting  albumin,  according  to  his  view. 

2  Mantegazza  admits  the  minimum  period  of  fecundating  power  of  man  as  from  eighteen  to  fifty- 
eight  years — that  is,  forty  years,  and  stating  that  at  each  ejaculation  the  quantity  of  semen  is  120 
drops,  and  that  a  single  drop  is  sufficient  for  impregnation,  comes  to  the  conclusion  that  a  man 
can  reproduce  480,000  times. 

Startling  as  this  statement  is,  that  of  Lode,  quoted  by  Ahlfeld,  is  still  more  remarkable— the 
number  of  spermatozoids  in  coition  discharged  in  the  vagina  is  226,257,900. 


CONCEPTION.  H3 

hours,  and  it  may  be,  as  illustrated  by  the  fecundation  of  the  hen's  egg 
twelve  days  before  it  is  laid,  several  days.  Hence  the  assertion  made 
by  some  women,  and  accepted  by  a  few  obstetricians,  that  a  peculiarly 
pleasurable  sensation  attends  fruitful  intercourse,  is  to  be  rejected.  The 
intercourse  may  be  with  cruel  violence,  or  the  woman  may  be  paralyzed 
by  fear,  or  submit  with  indifference,  or  even  with  loathing  and  disgust ; 
she  may  be  in  profound  sleep,  drugged,  or  anaesthetized  ;  or,  finally, 
artificial  introduction  of  the  seminal  fluid  into  the  uterine  cavity  may 
be  done,  yet  in  all  these  instances  fecundation  can  result.  In  such 
cases  pleasure  was  impossible,  and  in  some  both  mental  and  physical 
suffering  were  present.  The  role  of  woman  in  copulation  is  passive ; 
the  probability  is  her  pleasure  cannot  promote  nor  her  pain  prevent 
conception. 

THE  COMBINATION  OF  MALE  AND  FEMALE  ELEMENTS.  It  has 
been  held  that  the  spermatozoids  after  reaching  the  ovule  were  dissolved, 
then  by  osmosis  penetrated  its  walls  molecule  by  molecule,  and  the  de- 
velopment of  the  ovule  resulted  ;  it  was  vivified  by  a  sort  of  spermatic 
bath,  and  the  richer  the  bath  was  in  dissolved  spermatozoids,  the  more 
certain  would  be  impregnation.  Another  equally  improbable  explana- 
tion was  that  several  spermatozoids  entered  the  ovule,  the  greater  the 
number  entering  the  more  certain  the  fecundation,  and  then  were  dis- 
integrated and  were  mingled  with  the  yelk.  But  the  more  recent 
studies  of  fecundation  in  some  of  the  inferior  animals  render  it  in  the 
highest  degree1  probable,  and  it  is  quite  rational  too,  that  in  all  cases 
only  one  spermatozoid  is  concerned  in  normal  impregnation.  It  would 
seem  that  nature  teaches  the  law  of  monogamy  at  the  very  beginning  of 
life. 

Certain  changes  occur  in  the  ovule  independently  of  impregnation. 
The  germinal  vesicle  moves  toward  the  periphery  of  the  ovule,  and  from 
the  vesicle  there  is  formed  a  globule,  which  first  presents  as  a  bud-like 
process  projecting  from  the  surface  of  the  ovule,  then  the  part  nearest  the 
free  surface  of  the  ovule  becomes  constricted  and  separation  follows ; 
this  process  is  repeated  once,  or  oftener,  and  the  bodies  thus  originating 
from  the  germinal  vesicle,  and  ejected  from  the  ovule,  are  called  polar 
cells  or  globules.  The  formation  of  the  polar  cells2  may  occnr  while 
the  ovule  is  still  in  the  ovary,  but  more  frequently  afterward  ;  they  may 
precede  or  follow  impregnation.  These  statements  have  been  drawn 
from  observation  of  the  ova  of  some  of  the  inferior  animals ;  as  re- 
marked by  Balfour,  it  is  very  possible,  not  to  say  probable,  that  such 

1  Van  Beneden,  in  only  six  cases  of  many  thousands  of  impregnation  of  the  egg  of  the  ascaris 
studied  by  him,  found  that  two  spermatozoids  entered  the  ovule. 

2  The  apparently  useless  formation  of  polar  globules  has  been  given  different  explanations.   One 
is  that  these  globules  are  ejected  from  the  ovule  in  order  to  secure  space  for  the  segmentation  of  the 
vitellus.    Another  is  that  they  testify  to  a  descent  from  ancestral  forms  having  a  lower  organiza- 
tion, in  which  the  discharge  of  the  globules  plays  an  important  part,  as  in  the  parthenogenesis  of 
bees,  etc.    Balfour  suggests  as  one  of  the  reasons  for  the  ovule  having  this  function  the  prevention 
of  parthenogenesis.  It  is  the  final  act  of  the  ovule ;  unaided  it  can  do  nothing  more.   "  There  is  but 
little  doubt  that  the  ovum  is  potentially  capable  of  developing  by  itself  into  a  fresh  individual,  and 
therefore,  unless  the  absence  of  sexual  differentiation  were  very  injurious  to  the  vigor  of  the 
progeny,  parthenogenesis  would  certainly  be  a  very  constant  occurrence  ;  and  on  the  analogy  of 
the  arrangement  in  plants  to  prevent  self-fertilization,  we  might  expect  to  find  some  contrivance 
both  in  animals  and  in  plants  to  prevent  the  ovum  developing  by  itself  without  fertilization.    If 
my  view  about  the  polar  cells  is  correct,  the  formation  of  these  bodies  functions  as  such  a  con- 
trivance."   (Balfour :  Comparative  Embryology.)    Thus  parthenogenesis  is  prevented,  and  cross- 
fertilization  made  possible. 


114  PHYSIOLOG Y  OF  PREGNANCY. 

changes  are  universal  in  the  animal  kingdom,  but  the  present  state  of 
our  knowledge  does  not  justify  us  in  saying  so. 

It  is  generally  held  that  the  germinal  vesicle  is  not  entirely  cast  out 
in  the  form  of  polar  globules,  but  a  portion  remaining  in  the  ovule 
forms  the  female  pronucleus,  which  is  to  unite  with  the  male  pronucleus. 
The  latter  is  believed  to  be  formed  by  the  head  alone  of  the  spermato- 
zoid.  The  entrance  of  the  male  element  into  the  female  is  provided 
for  in  some  fish  by  a  minute  opening,  called  a  micropyle,  in  the  cover- 
ing of  the  ovule ;  this  opening  is  so  small  that  only  one  spermatozoid 
can  enter  at  a  time.  But  the  ova  of  the  mammiferse  show  no  such 
investment.  Duval  remarks  that  it  is  now  proved  that  a  great  number 
of  ovules  at  the  time  fecundation  occurs  are  simply  encircled  by  a  pel- 
lucid zone — that  is  to  say,  a  layer  more  dense,  and  having  a  special 
appearance,  but  which  in  a  normal  state  is  always  fluid  and  permeable. 
Fol,  of  Geneva,  states  that  putting  in  contact  with  an  ovule  liquids  con- 
taining vibrions,  the  latter  passed  through  this  pellucid  layer,  and  were 
found  in  the  yelk  ;  still  more,  then,  this  zone  is  permeable  by  the 
sperraatozoid. 

The  vitelline  membrane  is  a  secondary  formation,  and  is  not  found 
upon  the  unfecundated  egg ;  but  after  the  first  spermatozoid  has  pene- 
trated the  vitellus  the  ovule  is  rapidly  encysted  by  condensation  of  its 
peripheral  layer,  a  kind  of  catalytic  phenomenon  the  nature  of  which 
is  not  clear.  It  is  thus  seen  that  Nature  provides  for  the  entrance  ot 
one  spermatozoid,  but  closes  the  door  to  a  second,  and  if  by  mischance 
the  latter  enter,  the  result  will  be  a  double  monster. 

The  part  of  the  spermatozoid  which  enters  the  vitellus  increases  in 
size  and  is  the  male  pronucleus.  The  male  moves  toward  the  female 
pronucleus,  which  occupies  the  centre  of  the  ovule ;  the  latter  in  some 
cases  has  been  observed  to  lose  its  spherical  form  and  become  crescent- 
shaped,  so  as  to  receive  in  its  concavity  the  male  pronucleus.  After 
the  fusion  of  the  two  prouuclei  there  is  but  a  single  nucleus,  in  which 
are  initiated  all  the  changes  that  result  in  the  formation  of  a  new 
being.  Balfour  describes  the  act  of  impregnation  as  the  fusion  of  the 
ovum  and  the  spermatozoid,  and  the  most  important  feature  in  the  act 
appears  to  be  the  fusion  of  a  male  and  of  a  female  nucleus.  This  is 
brought  into  still  greater  prominence  by  the  fact  that  the  male  pronucleus 
is  the  metamorphosed  head  of  the  spermatozoid,  which  contains  part  of 
the  nucleus  of  the  primitive  spermatic  cell,  and  the  female  pronucleus 
is  the  product  of  a  primordial  ovum.  The  spermatic  cells  originate  in 
primordial  cells,  which  cannot  be  distinguished  from  primordial  ova, 
and  thus  the  impregnated  ovule  results  from  the  fusion  of  morphologi- 
cally similar  parts  in  the  two  sexes. 

TIME  OF  CONCEPTION.  This  cannot  be  certainly  known,  but  the 
time  when  coition  is  most  likely  to  be  followed  by  impregnation  is  well 
known  by  the  public  as  well  as  by  physicians.  The  "  conception  curve  " 
given  by  Foektistow1  shows  that  conception  is  most  liable  to  occur  from 
coition  in  the  first  seven  days  following  menstruation  ;  the  first  day 
after  the  flow  ceases  has  the  highest  percentage,  and  from  this  time  the 

1  Op.  cit. 


CONCEPTION.  H5 

latter  gradually  declines.  Hensen's  conclusions  are  in  accordance.  But 
while  conception  is  very  improbable  during  a  certain  portion  of  the 
menstrual  interval,  it  cannot  be  affirmed  that  it  is  impossible  at  any 
time. 

FATE  OF  THE  SPERMATOZOIDS  NOT  CONCERNED  IN  IMPREGNATION. 
As  has  been  previously  stated,  it  is  almost  certain  that  in  human  beings, 
as  has  been  proved  to  be  the  fact  in  some  of  the  inferior  animals,  only 
one  spermatozoid  is  concerned  in  impregnation,  and  the  question  natur- 
ally arises,  What  becomes  of  the  multitude  who  have  no  part  in  this 
process,  a  number  much  greater  than  Penelope's  suitors  during  the  long 
absence  of  Ulysses.  Is  it  not  possible  that  they  may  permanently 
modify  the  organism  or  the  undeveloped  ovules  so  that  the  product  of  a 
future  pregnancy,  though  by  another  father,  may  be  affected?1  The 
heredity  of  influence  is  that  observed  in  the  children  born  by  a  widow 
who  remarries,  these  children  resembling  morally  and  physically  the 
first  husband.  Occasional  instances  of  such  heredity  occur,  and  it  is 
claimed  that  in  reproduction  in  the  inferior  animals  the  first  sire  may 
materially  modify  the  offspring  of  subsequent  sires.  Admitting  the 
fact,  possibly  the  factors  in  such  modification  may  be  the  original  sper- 
matozoids  that  did  not  contribute  to  the  first  conception.  Heredity  of 
influence  has  also  been  termed  indirect  atavism,  and  more  recently 
telegony.  Lingard2  has  given  a  remarkable  instance  :  The  widow  of  a 
hypospadian  eighteen  months  after  the  death  of  her  husband  contracted 
a  second  marriage,  the  new  husband  not  being  a  hypospadian,  and 
having  no  history  of  any  such  deformity  in  his  family.  Consequent 
upon  this  marriage  she  had  four  sons,  all  hypospadians. 

PRODUCTION  OF  SEX.  The  essential  causes  of  the  differences  of  sex 
are  not  known.  By  Sadler  and  Hofacker  the  following  conclusions 
were  drawn  as  to  the  influence  of  age  :  If  the  husband  be  younger  than 
the  wife,  there  are  as  many  boys  as  girls ;  if  both  are  of  the  same  age, 
there  are  1029  boys  to  1000  girls  ;  if  the  husband  is  older,  1057  boys 
to  1000  girls.  These  laws  are  not  to  be  accepted  as  conclusive.  The 
normal  proportion  between  female  and  male  births  is  100  to  105  or  106. 
But  in  the  case  of  illegitimate  births  the  proportion  is  reversed,  at 
least  for  the  children  first  born ;  that  is  to  say,  in  such  births  females 
are  more  numerous  than  males.  The  proportion  of  male  children  to 
females  is  slightly  greater  in  the  country  than  in  the  city.  The  chances 
of  the  young  wife  having  at  her  first  pregnancy  a  boy  are  at  their  maxi- 
mum, while  those  of  the  matron  near  the  close  of  her  reproductive  life 
are  at  their  minimum.  Swedish  statistics  prove  that  in  the  nobility, 
the  age  of  the  husband  being  greater  than  that  of  the  wife,  there  are 
only  98.3  male  to  100  female  births ;  this  reverses  one  of  the  rules 
given  by  Sadler,  according  to  which  there  ought  to  be  a  preponder- 
ance of  male  births.  Bertillou  states  that  the  influence  of  the  ages 

1  This  is  by  some  called  infection  of  the  mother.    Dolfiris  regards  it  as  without  positive  proofs. 
He  also  quotes  Colin  as  saying :  If  the  male  can  indeed,  in  fecundating  the  female,  exercise  an 
action  upon  the  eggs  contained  in  the  ovary,  and  which  contribute  to  subsequent  gestations,  this 
influence  is  very  difficult  to  conceive.  —  Nouveau  Dictionnaire  de  M6decine  et  de  Chirurgie 
Pratiques,  tome  xxxiv. 

Modification  of  the  ova  was  the  view  of  the  illustrious  Haller,  while  foetal  inoculation  of  the 
mother  was  upheld  by  the  late  Professor  Alexander  Harvey,  of  the  University  of  Aberdeen,  in  his 
little  volume,  Foetus  in  Utero,  London,  1886. 

2  Lancet,  April  19, 1884. 


116  PHYSIOLOGY  OF  PREGNANCY. 

of  the  parents  upon  the  proportion  of  the  sexes,  if  it  exists,  may  be 
neutralized  by  the  inherent  qualities  appertaining  to  the  parents. 

Kaltenbach  calls  attention  to  the  fact  established  by  Hecker-Ahlfeld, 
that  there  is  a  great  excess  of  male  births  in  old  primipane,  this  being 
124-140  : 100.  He  also  states  that  in  young  colonies  too,  in  which  the 
number  of  females  is,  relatively  to  males,  very  small,  so  that  not  merely 
very  young  females,  but  also  quite  old  marry,  the  excess  of  male  births 
is  very  great. 

Some  have  held  that  the  sex  was  preformed  in  the  ovule,  and  thus 
there  are  male  and  female  eggs.  Still  another  opinion  held  by  some 
physiologists  was  that  the  greater  vigor  of  one  or  the  other,  husband  or 
wife,  at  the  time  of  fruitful  coition  determined  the  sex,  each  sex  tending 
to  repeat  itself.  More  recently  the  view  that  each  sex  tends  to  produce 
the  opposite  has  been  received  with  some  favor.  Thus,  according  to 
Janke,1  if  a  boy  be  desired,  the  sexual  sphere  of  the  wife  and  her  sexual 
appetite  must  be  strengthened  to  the  utmost  by  generous,  even  luxurious 
diet,  while  the  husband  lives  more  as  a  vegetarian  ;  a  week  after  men- 
struation is  the  most  favorable  time  for  coition.  Those  who  will  consult 
Debay's  work,2  will  find  that  Janke  has  been  anticipated  in  his  advice 
as  to  means  for  securing  the  creation  of  a  male. 

Mantegazza,3  quoting  from  a  report  to  the  Anthropological  Society  of 
Berlin  by  Miklucho-Maclay,  refers  to  hypospadias  made  for  Malthusian 
purpose  among  some  of  the  Australian  tribes ;  thus,  in  one  tribe  there 
were  300  mutilated,  and  only  three  or  four  left  with  the  penis  intact ; 
to  this  small  number  the  continuance  of  the  tribe  was  left,  and  the 
female  births  greatly  exceeded  the  male. 

•  RELATIVE  INFLUENCE  OF  THE  FATHER  AND  THE  MOTHER  UPON  THE 
OFFSPRING.  This  subject  is  one  of  great  interest.  Runge,  Lehrbuch  der  Geburts- 
hilfe,  1894,  refers  to  the  old  and  widespread  belief,  illustrated  by  many  ex- 
amples, that  the  degree  and  condition  of  the  intelligence  are  inherited  from  the 
mother,  character  and  inclination  from  the  father — this  position  being  maintained 
by  Schopenhauer.  Goethe  said :  "  From  my  father  I  inherit  my  frame  and  the 
steady  guidance  of  my  life ;  from  my  dear  little  mother,  my  happy  disposition 
and  love  of  story-telling."  Debay,  in  his  work  previously  quoted,  upholds  this 
thesis :  Physical  and  moral  qualities  are  transmitted  from  the  father  to  the 
daughter,  from  mother  to  son,  and  he  adduces  many  illustrious  examples  as 
proofs.  Gal  ton,  Hereditary  Genius,  finds  one  distinguished  man  among  4000 
ordinary  men,  and  one  illustrious  man  in  a  million.  In  studying  the  relation 
between  transmission  by  the  male  and  by  the  female,  that  for  statesmen,  judges, 
literary  and  scientific  men  is  as  70  to  30.  Among  poets  and  artists,  too,  ma- 
ternal influence  was  much  less  than  paternal.  On  the  other  hand,  among  theo- 
logians the  female  influence  was  represented  by  73,  that  of  the  male  being  27. 
It  is  shown,  in  regard  to  this  class, "  that  the  influence  of  the  female  line  has  an  un- 
usually large  effect  in  qualifying  a  man  to  become  eminent  in  the  world." — Galton. 
"  It  is  seen,"  Mantegazza  remarks  in  his  Hygiene  de  I' Amour,  "  that  Galton 
overturns  a  very  popular  belief,  according  to  which  great  men  almost  always 

1  Centralbl.  flir  Gynakol.,  1891. 

2  Hygiene  et  Physiologic  du  Marriage  :  Debay  suggests  that  in  order  a  boy  shall  be  produced  the 
wife  must  for  twenty  or  twenty-five  days  before  the  impregnating  coition  live  chiefly  on  nitro- 
genous food.    There  does  not  seem  a  greater  probability  of  the  truth  of  this  theory  of  determining 
the  creation  of  a  male,  than  that  of  a  recent  writer  as  to  the  relation  between  nitrogen  and  evil : 
we  might  almost  say  boys  and  badness  come  from  nitrogen.    The  writer  referred  to  makes  the  fol- 
lowing statement :  "Every  good  thought  increases  the  proportion  of  oxygen,  as  a  deep  breath  does, 
and  lessens  that  of  nitrogen,  making  the  body  finer  and  more  beautiful.    Every  evil  thought  or 
impulse  that  is  indulged  increases  the  nitrogen,  and  has  the  reverse  eflect  on  body  and  soul." — The 
Arena,  June,  1894. 

3  L' Amour  dans  1'humanite. 


CONCEPTION. 


117 


have  mothers  of  superior  intelligence,  while  the  father  rarely  transmits  his 
genius  to  his  son.  Nevertheless  I  believe  Galton  is  wrong,  and  that  the  common 
belief  is  reasonable ;  without  collecting  statistics,  we  know  how  great  the  amount 
of  talent  transmitted  by  the  uterine  way." 

The  excess  of  male  over  female  births  is  somewhat  greater  in  Phila- 
delphia than  the  average,  which  is,  100  females  to  106  males.  In  five 
years  from  1868  to  1872,  inclusive,  the  relation  was  100  to  a  fraction 
over  110.  In  one  year,  1870,  the  relation  was  100  to  a  fraction  over 
113.  In  the  five  years  from  1888  to  1892,  inclusive,  this  relation  was 
100  to  a  fraction  over  109. 

TIME  OF  YEAK  MOST  FAVORABLE  TO  CONCEPTION.  The  subjoined 
table  comprising  the  births  in  Philadelphia  each  mouth  during  two 
periods,  each  of  five  years — the  first  from  1868  to  1872  inclusive,  and 
the  second  1888  to  1892,  also  inclusive — shows  the  births  in  each 
month,  the  months  being  readily  divided  into  three  periods,  maximum, 
mean,  and  minimum  of  births.  There  are  also  shown  the  months,  simi- 
larly divided,  in  which  conception  occurs  in  relative  frequency  ;  the  dif- 
ference between  March  and  July  as  conception  months  is  very  striking. 


Month  of  birtl 
December 
August 
July 

i. 

Mor 

ith  of  conception.                           Number  of  births. 
March    21,001 
November     20,410 
October  20,396 
January  20.178 

December     19,934 
April      19,812 

October 

September 
January 
November 
March  . 

February 
June 
May      . 

April     . 

February      19,288 

June      18,745 
May       18,407 

September    18,402 
August                                          .        .    17,555 

July       16,886 

The  following  is  an  abstract  of  statements  made  by  Ploss1  in  regard  to  the  in- 
fluence of  the  seasons  upon  conception.  The  fact  that  there  is  an  increase  in  the 
number  of  conceptions  at  certain  times  of  the  year  does  not  indicate  that  there 
is  a  greater  ability  on  the  part  of  the  female  to  conceive  at  these  times,  or  any 
change  in  the  physiological  condition  of  the  female  sexual  organs.  The  influ- 
ence of  the  seasons  upon  the  male  is  also  to  be  taken  into  consideration. 
Villerme  found  that  the  maximum  of  conceptions  in  Europe  occurs  in  May  and 
June,  and  he  attributed  it  to  the  influence  of  spring.  In  order  to  justify  this 
opinion  he  extended  his  observations  to  those  parts  of  the  world  where,  while 
the  seasons  follow  in  the  same  order,  they  occur  at  different  times,  e.  g.,  Buenos 
Ayres,  and  found  the  results  the  same.  The  times  when  marriages  are  most,  and 
those  when  they  are  least  frequent,  have  no  apparent  influence  upon  the  number 
of  conceptions  according  to  the  season  of  the  year.  On  the  other  hand,  the 
periods  of  comparative  rest,  of  hard  labor,  and  scarcity  of  food  have  a  marked 
influence.  The  number  of  conceptions  is  lowered  by  the  harvesting  season, 
scarcity  of  food,  and  by  strict  observance  of  religious  fasts,  as  Lent.  "  Those 
conditions  which  strengthen  us  increase  our  fertility,  and  those  which  weaken 
or  depress  us,  or  especially  such  as  undermine  the  health,  lessen  it,  though  fer- 
tility is  by  no  means  governed  by  health  alone." 

Wappenhaus's  conclusions  from  his  studies  of  the  birth-rate  in  Sardinia,  Bel- 
gium, the  Netherlands,  Saxony,  Sweden,  and  Chili  are  as  follows  :  The  maximum 
of  conceptions  occurs  in  May  and  June.  The  cause  is  the  vivifying  influence  of 
spring,  aided  by  the  habits  and  customs  of  the  church  in  all  Catholic  countries. 
There  is  a  gradual  decrease  to  the  minimum,  which  is  in  September  and  October. 
The  cause  is  in  the  increased  heat  of  summer,  and  in  the  epidemic  diseases  re- 
sulting therefrom,  aided  by  the  hard  work  of  harvest.  In  Sweden  this  maximum 
is  in  January.  The  cause  is  found  in  social  customs  and  in  the  religion.  The 

1  Op,  cit. 


118 


PHYSIOLOGY  OF  PREGNANCY. 


dissipations  incident  to  the  period  of  Carnival,  and  the  strict  observance  of  Lent, 
lessen  the  maximum  in  Catholic  countries. 

In  Italy  the  maximum  differs  in  the  north  and  in  the  south.  In  the  latter  it  is 
in  April,  but  in  the  former  in  July. 

Illegitimate  conceptions  are  more  under  the  influence  of  physical  conditions, 
e.  g.,  the  seasons,  than  are  legitimate  conceptions.  In  western  Europe  the  greatest 
number  of  illegitimate  offspring  are  conceived  in  spring  and  summer,  the  fewest 
in  fall  and  winter;  the  difference  is  much  less  marked  in  the  conceptions  occurring 
in  the  married. 

In  Russia  the  greatest  number  of  conceptions  occur  in  April  and  in  January. 

CHANGES  IN  THE  FECUNDATED  OVULE.  The  first  of  these  changes 
is  segmentation,  or  cleavage,  the  sphere  dividing  into  two  spheres.  The 
process  of  division  occurs  in  the  nucleus  first,  and  is  followed  by  that 
of  the  vitelline  mass  surrounding  the  two  newly  formed  nuclei,  so  that 
each  new  sphere  has  a  part  of  the  original  nucleus.  These  spheres 
again  similarly  divide,  thus  the  two  become  four,  which  also  divide  and 
eight  are  formed ;  subdivision  after  subdivision  occurs  until  the  entire 
vitelline  mass  has  been  converted  iuto  a  number  of  minute  spheres 
which  from  their  supposed  resemblance  to  a  mulberry  have  been  called 
the  muriform  body. 

These  spheres  are  unequal  in  size  and  fulfil  different  purposes  in  the 
process  of  organization.  The  larger  and  more  transparent  are  called 
epiblastiv  from  ITTI,  upon,  and  /Syaoror,  germ ;  the  smaller  hypoblastic, 
from  vn-b,  under,  and  p-yaaTo?,  germ.  The  segmentation,  too,  is  not 
simultaneous  in  the  spheres  after  eight  are  formed,  but  begins  in 
the  epiblastic  spheres ;  a  cup-shaped  cavity  is  formed  by  them  in  which 
the  hypoblastic  spheres  are  placed,  making  a  solid  central  mass. 


OPTICAL  SECTION  OF  A  RABBIT'S  OVUM  AT  Two  STAGES  CLOSELY  FOLLOWING  SEGMENTATION. 

(After  E.  VAN  BENEDEN.) 
ep.  Epiblast.    hy.  Primary  hypoblast.    bp.  Van  Beneden's  blastopore. 

It  will  be  seen  at  the  end  of  segmentation1  that  the  epiblast  cells  are 
somewhat  the  smaller,  that  they  are  clear,  and  irregularly  cubical  in 
form  ;  the  hypoblast  cells,  on  the  other  hand,  are  polygonal  in  form  and 
granular  and  opaque  in  appearance.  A,  Fig.  65,  shows  an  opening  in 
the  epiblast  covering  of  the  hypoblast  cells ;  this  opening  is  called  the 

i  Balfour. 


FORMATION  OF  DECIDUOUS  MEMBRANES. 


119 


blastopore  ;  it,  however,  is  soon  closed,  as  represented  in  _B,  Fig.  65,  by 
the  growth  of  epiblast  cells. 

After  the  segmentation  and  arrangement  of  the  cells  the  ovum 
passes  into  the  uterus ;  this  is  supposed  to  occur  within  five  or  six  days 
after  fecundation. 

FORMATION  OF  THE  DECIDUOUS  MEMBRANES.  Before  tracing  the 
further  development  of  the  ovum  it  is  advisable  to  refer  to  the  changes 
in  the  uterine  mucous  membrane  incident  to  the  beginning  of  pregnancy, 
the  fitting  up  of  the  interior  of  the  house  in  which  the  new  being  is  to 
dwell  during  the  many  months  of  intra-uterine  development. 

It  was  formerly  taught  by  John  Hunter  and  others  that  the  stimulus 
of  pregnancy  produced  an  inflammatory  exudate  upon  the  uterine 
mucous  membrane,  and  thus  a  closed  sac  occupied  the  uterine  cavity. 
The  fecundated  ovule  could  only  enter  the  uterus  by  pushing  before  it 
that  part  of  this  new  membrane  which  was  in  relation  with  the  uterus 
in  the  immediate  vicinity  of  the  oviduct  through  which  it  came,  and  the 
mouth  of  which  was  covered  ;  the  portion  thus  pushed  away,  therefore, 
became  a  reflected  membrane,  and  hence  was  called  the  membrana  reftexa, 
while  that  which  remained  adherent  to  the  remaining  portion  of  the 
uterine  mucous  membrane  was  a  true  membrane,  unchanged  in  its  rela- 
tions, and  received  the  designation  of  membrana  vera.  Finally,  the 
surface  to  which  the  reftexa  had  been  attached  was  left  bare,  but  a  new 
exudate  covered  it,  making  a  membrane  which,  because  of  its  late  forma- 
tion, was  called  the  membrana  serotina.  As  these  membranes  were  dis- 
charged with  the  ovum  at  the  end  of  pregnancy,  they  were  called 
deciduous  or  caducous. 

FIG.  67. 


DIAGRAM  SHOWING  HUNTER'S  THEORY  OF 

THE  DECIDUOUS  MEMBRANES. 
a.  Decidua  vera.    6.  Decidua  reflexa. 


FIRST  STAGE  OF  FORMATION  OF  DECIDUA. 


Hunter's  theory  was  accepted  as  explaining  the  fact  that  in  abortion 
the  unbroken  ovum  showed  a  complete  investment  from  the  uterine 
mucous  membrane.  While  the  theory  has  been  rejected,  the  names  of 
the  deciduous  membranes  are  retained,  and,  therefore,  an  explanation  of 
the  origin  of  these  names  was  necessary. 

The  deciduous  membranes  originate  as  follows :  The  uterine  mucous 
membrane  is  swelled  and  thrown  into  folds  ;  the  ovum  is  thus  stopped 
from  descent  after  it  enters  the  uterine  cavity,  and  lodges  in  one  of  the 


120 


PHYSIOLOGY  OF  PREGNANCY. 


intervals  between  these  folds ;  there  is  formed  at  its  place  of  lodgment 
a  cup-shaped  cavity,  a  condition  which  is  represented  in  Fig.  67. 


FIG.  68. 


FORMATION  OF  DECIDUA  COMPLETED. 
b.  Decidua  vera.    o.  Decidua  reflexa.    c.  Decidua  serotina. 

The  mucous  membrane  upon  which  the  ovum  rests,  the  membrane 
which  in  the  Hunterian  theory  was  the  serotina,  is  now  called  from  its 


FIG.  69. 


SECTION  THROUGH  THE  MATERNAL,  MEMBRANES  IN  THE  SECOND  MONTH  OF  PREGNANCY.  X  20. 

D.v.  Decidua  vera.    D.s.  Decidua  serotina.   R.  Decidua  reflexa.    The  ovum  has  been 

removed  from  its  point  of  fixation  between  R  and  D.s. 

final  purpose  the  placental  decidua.  The  borders  of  the  cup-like  cavity 
grow  higher,  extend  toward  a  common  centre,  and  finally  meet  and 
unite  over  the  ovum,  forming  a  complete  covering ;  thus  that  which 


FORMATION  OF  DECIDUOUS  MEMBRANES. 


121 


was  called  the  decidua  reflexa,  but  now  appropriately  termed  the  decidua 
of  the  ovule  or  ovular  decidua,  is  formed. 

The  third  deciduous  membrane,  decidua  vera,  covers  all  the  internal 
uterine  surface,  including  that  upon  which  the  ovum  rests ;  it  is  neces- 
sarily continuous  with  the  other  membranes  ;  it  was  formerly  called,  as 
has  been  stated,  the  decidua  vera,  but  from  its  relation  to  the  uterine 
wall  it  may  be  appropriately  termed  the  uterine  decidua. 

Subsequent  changes  in  the  deciduse  will  be  considered  in  connection 
with  the  formation  of  the  placenta  and  with  the  uterine  changes  caused 
by  pregnancy,  and  the  history  of  the  development  of  the  ovum  will  be 
now  resumed.  ..  ... 

THE  BLASTODERMIC  VESICLE.  We  have  found'  the  segmentation 
of  the  vitellus  and  the  vitelline  nucleus  the  first  step  in  developmental 
changes ;  subsequent  segmentations  occurred,  but  these  were  unequal 
and  not  simultaneous,  and  the  products  were  two  kinds  of  cells  differ- 
ing in  number,  in  form,  in  size,  in  arrangement,  and  as  to  transparency. 
The  next  step  after  the  inclosure  of  the  hypoblast  by  the  epiblast  cells 
is  the  formation  of  the  blastodermic  vesicle. 

PIG.  70. 


bv.   Cavity  of  the  blastodermic  vesicle,  or  yelk  sac.     ep.  Epiblast.     hy.  Primitive  hypoblast. 
zp.  Mucous  envelope,  zona  pellucida.    (After  E.  VAN  BENEDEN.) 

A  fissure  now  appears  between  the  epiblast  and  hypoblast  cells,  and 
this  increasing  cavity  separates  the  two  at  all  points,  except  at  that  cor- 
responding with  the  position  which  was  occupied  by  the  blastopore. 
There  results  a  vesicle  whose  wall,  inclosed  by  the  vitelline  membrane, 
is  formed  by  epiblast  cells  with  the  hypoblast  cells  accumulated  upon 
a  part  of  its  interior  surface,  and  this  is  called  the  blastodermic  vesicle, 
or  the  blastoderm.  In  the  subjoined  diagram  of  the  rabbit's  ovum, 
between  seventy  and  ninety  hours  after  impregnation,  it  will  be  seen 
that  the  vitelline  membrane,  membrana  pellucida,  is  external,  then 
the  flattened  epiblast  cells  completely  line  it,  while  the  hypoblast  cells 
are  arranged  in  a  lens-shaped  mass  within  the  epiblastic  investment. 


122  PHYSIOLOGY  OF  PREGNANCY. 

The  growth  of  the  vesicle  is  very  rapid,  and  the  hypoblast  losing  its 
lens-shape  is  flattened  and  extended  upon  the  inner  side  of  the  epiblast. 
"  The  central  part,  however,  remains  thicker,  and  is  constituted  of  two 
rows  of  cells,  while  the  peripheral  part,  the  outer  boundary  of  which  is 
irregular,  is  formed  of  an  imperfect  layer  of  amoeboid  cells,  that  con- 
tinually spread  further  and  further  within  the  epiblast.  The  central 
thickening  of  the  hypoblast  forms  an  opaque  circular  spot  on  the  blasto- 
derm, which  constitutes  the  commencement  of  the  embryonic  area." 
Next  a  third  layer  intervenes,  the  mesoblast,  from  /^ffof,  middle,  and 
f&aorbCj  germ  ;  the  formation  of  the  mesoblastic  layer  is  not  perfectly 
understood,  but  probably  it  originates  in  part  from  each  of  the  primi- 
tive layers.  From  these  layers,  epiblast,  hypoblast,  and  mesoblast,  all 
the  parts  of  the  foetus  are  formed.  "  In  the  higher  vertebrates  the  fol- 
lowing structures  are  always  derived  from  the  epiblast — namely,  epider- 
mis, epithelium  of  mouth,  nose,  and  of  cloaca  when  present;  the  nerve 


FIG.  71. 


DIAGRAMMATIC  VIEWS  OF  BLASTODERMIC  VESICLE  OF  A  RABBIT  ON  THE  SEVENTH  DAY. 
In  the  left-hand  figure  the  vesicle  is  seen  from  above ;  in  the  right-hand  figure  from  the  side. 
The  white  patch  (ag)  is  the  germinal  area ;   and  the  slight  constriction  (ge)  marks  the  limit  to 
which  the  hypoblast  has  extended. 

•cells  of  the  brain,  spinal  cord,  and  ganglia ;  the  neuroglia  or  support- 
ing tissue  of  the  nerve  elements  in  the  brain  and  spinal  cord  ;  the  retina 
the  lens  of  the  eye;  epithelium  of  the  conjunctiva;  the  special  sensory 
'  end  organs '  of  nerve  fibres  in  ear,  nose,  mouth,  and  skin.  From 
the  hypoblast  are  derived  the  epithelium  of  the  digestive  canal  except 
of  the  buccal  cavity  and  cloaca ; "  of  the  trachea,  bronchial  tubes,  and 
air-cells ;  the  cylindrical  epithelium  of  the  ducts  of  the  liver,  pancreas, 
thyroid  body,  and  other  glands  of  the  alimentary  canal.  The  muscles, 
bones,  connective  tissue,  heart  and  bloodvessels,  lymphatics,  and  the 
urinary  and  generative  organs  are  formed  from  the  mesoblast. 

The  embryonic  area,  area  germinativa,  becomes  oval ;  it  is  composed 
of  epiblast,  hypoblast,  and  mesoblast.  Following  the  pyriform  ap- 
pearance of  the  embryonic  area  there  is  found  at  its  posterior  and  nar- 
rower end  the  primitive  line  or  streak  ;  a  little  afterward  the  primitive 


FORMATION  OF  DECIDUOUS  MEMBRANES. 


123 


line  is  seen  to  mark  the  middle  of  a  straight,  shallow  groove,  called  the 
primitive  groove.  The  next  step  is  the  formation  of  the  axial  or 
medullary  groove  upon  the  upper  part  of  the  embryonic  area ;  upon 
each  side  of  the  groove  are  folds,  the  medullary  folds,  "  which  meet  in 
front,  but  diverge  behind,  and  enclose  between  them  the  foremost  end 
of  the  primitive  streak  ;  the  groove  is  converted  into  a  closed  tube,  the 
neural  canal,  which  is  the  beginning  of  the  central  nervous  system." 


FIG.  72. 


SHOWING  THE  EMBRYONIC  AREA  WITH  PRIMITIVE  STREAK  AND  PRIMITIVE  GROOVE  OF  THE  OVUM 

(RABBIT)  AT  THE  SEVENTH  DAY. 

ae.  Embryonic  area.     gp.  Primitive  streak,  or  groove,     av.  Vascular  area.     gm.  Medullary 
groove.    Ip.  Primitive  line. 

THE  EMBRYO.  The  embryo,  from  ipjjpvoq,  that  which  grows  in 
another's  body,  at  first  presenting  form,  results  from  a  folding  inward 
of  a  portion  of  the  blastodermic  vesicle,  and  presents  somewhat  the 
shape  of  a  boat ;  the  extremities,  however,  are  unequal  in  size,  the 
larger  is  called  the  cephalic  or  head  end,  while  the  smaller  is  the  caudal 
or  tail  end.  This  infolding  of  the  blastodermic  vesicle  destroys  its 
spherical  form,  and  a  constriction  divides  it  into  two  parts,  the  smaller 
of  which  is  embryonic  while  the  larger  is  called  the  yelk  sac  or  the 
umbilical  vesicle ;  an  opening  corresponding  with  the  umbilicus  offers 
free  communication  between  the  two. 

FORMATION  OF  THE  AMNioN.1  The  development  of  the  uterine 
deciduous  membranes  which  furnish  the  external  investment  of  the 

1  The  term  amnios  was  first  employed  by  Empedocles  to  designate  the  innermost  membrane 
covering  the  young,  and  was  also  subsequently  applied  to  the  fluid  contained  in  it.  Preyer 
believes  that  it  was  derived  from  a/uevo<;,  thin,  delicate  ;  but  this  became  corrupted,  changed  into 
amnios,  and  then  a  false  criticism  made  it  mean  "the  membrane  of  the  sheep,"  "  the  water  of 
the  sheep,"  as  if  derived  from  the  word  afivbf,  a  lamb. 


124 


PHYSIOLOGY  OF  PREGNANCY. 


ovum  has  been  given,  and  there  will  be  now  considered  the  origin  of 
the  internal  membrane  of  the  embryonic  sac. 

At  both  the  cephalic  and  the  caudal  end  of  the  embryo  the  mesoblast 
is  divided  into  a  splanchnic  and  a  somatic  layer ;  then  a  fold  composed 
of  the  somatic  mesoblast  and  epiblast  begins  to  rise  up  from  and  grow 
over  these  extremities,  and  also  a  fold  from  each  side ;  the  cephalic  fold 
appears  first.  These  double  folds  are  the  beginning  of  a  membrane 
called  the  amnion.  The  caudal,  cephalic,  and  lateral  folds  finally  meet 
and  unite,  and  thus  form  a  complete  sac.  As  is  seen  in  Fig.  73,  each 
fold  is  double;  the  inner  layers  form  what  is  called  the  true  amnion, 
and  the  outer  the  false.  The  false  amnion  with  the  epiblast  from  the 
umbilical  vesicle  forms  the  subzonal  membrane. 

FIG.  73. 


DIAGRAM  OF  THE  FCETAL  MEMBRANES  OF  A  MAMMAL.  (STRUCTURES  WHICH  EITHER  ARE  OR  HAVE 
BEEN  AT  AN  EARLIER  PERIOD  OF  DEVELOPMENT  CONTINUOUS  WITH  EACH  OTHER  ARE  REPRESENTED 
BY  THE  SAME  CHARACTER  OF  SHADING.) 

pc.  Zona  with  villi.  sz.  Subzonal  membrane.  E.  Epiblast  of  embryo,  am.  Amnion.  AC. 
Amniotic  cavity,  it.  Mesoblast  of  embryo.  H.  Hypoblast  of  embryo.  UV.  Umbilical  vesicle. 
al.  Allantois.  ALC.  Allantoic  cavity. 

THE  ALLANTOIS.  As  the  embryo  grows  and  the  amnion  is  developed, 
the  umbilical  vesicle  lessens,  but  another  vesicle  is  formed,  the  allantois 
or  allantoid,  from  d/Ud?,  sausage,  and  ei6oe,  likeness,  because  of  its  fancied 
resemblance  to  a  sausage. 

Observers  differ  as  to  the  origin  of  the  allantoid.  Some  claim  it  is  derived 
from  the  terminal  portion  of  the  intestine,  others  from  the  Wolffian  bodies,  and 
still  others  directly  from  the  walls  of  the  pelvic  cavity  by  an  expansion  from 
the  mesoblast  and  hypoblast.  Kolliker  describes  the  allantoid  in  the  embryo  of 
the  rabbit  as  appearing  under  the  form  of  a  hollow  body  in  relation  with  the 
posterior  intestine,  lined  by  intestinal  epithelium,  and  covered  externally  by  a 
prolongation  of  the  nbro-intestinal  layer,  and  thus  formed  makes  a  projection  in 
the  free  space  between  the  amnion,  the  serous  envelope,  and  the  vitelline  sac  or 
umbilical  vesicle. 


FCETAL  APPENDAGES.  125 

A  part  of  the  allantoid  protrudes  from  the  embryo,  and  a  constric- 
tion separates  it  from  the  intra-embryonic  portion  ;  the  latter  becomes 
in  a  later  stage  of  development  the  urinary  bladder,  while  the  isthmus 
connecting  the  two  is  the  urachus,  and  at  birth  is  a  fibrous  cord  uniting 
the  summit  of  the  bladder  to  the  umbilicus.  The  extra-embryonic 
portion  is  at  first  spherical,  but  projecting  to  the  subzoual  membrane, 
it  becomes  flattened  and  spread  out  like  an  umbrella,  lining  the  mem- 
brane throughout  nearly  or  quite  all  its  extent.  The  external  layer  of 
the  allantoid  is  mesoblastic  in  its  origin  ;  this  layer  fuses  with  the  sub- 
zonal  membrane,  and  from  the  fusion  the  second  of  the  investing  mem- 
branes of  the  foetus  is  formed.  The  allantoid,  especially  that  part 
contributing  to  the  formation  of  the  chorion,  becomes  very  vascular; 
the  blood  is  brought  to  it  by  two  arteries,  called  the  allantoic,  which 
arise  from  the  terminal  bifurcation  of  the  aorta,  and  returned  by  one, 
or  in  some  cases  two  veins,  joining  the  vitelliue  veins  from  the  yelk 
sac.  The  vessels  of  the  allantoid  penetrate  into  the  chorial  villi  with 
which  they  are  in  relation.  The  sac  of  the  allantoid  incloses  a  fluid 
which  is  at  first  colorless,  but  afterward  is  yellow  or  amber-like ;  it  is 
alkaline,  and  contains  chloride  of  sodium,  albumin,  sugar,  urea,  aud  its 
derivatives,  and  a  substance  called  allantoidine,  which  has  in  a  high 
degree  the  property  of  converting  fats  into  an  emulsion.  The  chief 
use  of  the  allantoid  in  development  seems  to  be  in  conducting  the 
allantoic,  afterward  the  umbilical,  arteries  to  that  part  of  the  chorion 
where  the  placenta  is  formed. 

FCETAL  APPENDAGES.  These  are  the  membranes  forming  the  sac 
inclosing  the  foetus,  consisting  of  the  decidua?,  that  of  the  ovum  and  of 
the  uterus — the  reftexa  and  the  vera,  according  to  John  Hunter's 
theory — which  become  united  so  as  to  form  a  single  structure,  the  cho- 
rion and  the  amnion — the  placenta  and  the  umbilical  cord. 

THE  AMNION.  This  is  the  most  internal  of  the  membranes,  and 
forms  a  sac  completely  surrounding  the  foetus.  Its  origin  has  been 
stated  and  its  further  development  can  be  traced  in  connection  with 
Figs.  73,  74,  and  75. 

In  Fig.  74  the  cephalic  and  caudal  folds  are  seen  projecting  over 
the  back  of  the  embryo;  the  former  fold,  first  in  formation,  is  somewhat 
larger  than  the  other.  These  folds  approach  very  near  each  other,  and 
the  intervening  space  is  so  small  that  it  is  called  the  amniotic  umbilicus. 
Fig.  75  shows  them  united.  It  is  also  seen,  as  previously  stated,  that 
each  fold  is  composed  of  two  layers,  and  thus  the  completed  amnion  has 
two  walls,  one  internal  and  the  other  external.  The  former  is  separated 
throughout  almost  its  entire  extent  from  the  foetus  by  a  fluid  called 
the  liquor  amnii,  but  is  continuous  with  it  at  the  umbilicus ;  this  is  the 
permanent,  or  true,  amnion.  The  external  layer,  or  false  amniou,  is  ap- 
plied to  the  internal  face  of  the  vitelline  membrane.  The  internal  or 
true  amnion  covers  the  foetal  face  of  the  placenta  and  also  the  umbilical 
cord,  furnishing  a  complete  sheath  to  the  latter.  It  is  thin  and  trans- 
parent, and  is  composed  of  two  layers,  the  internal,  which  is  epithelial, 
and  the  external,  which  is  fibrous.  It  is  without  nerves,  but  compara- 
tively recent  investigations  seem  to  prove  the  presence  of  bloodvessels  ; 
these  are  called  vasa  propria.  From  the  middle  of  pregnancy  the 


126 


PHYSIOLOGY  OF  PREGNANCY. 


amnion  is  applied  directly  to  the  chorion,  and  united  to  it  by  a  gelatinous 
layer  of  tissue,  the  tunica  media  of  Bischoff ;  it  is  also  called  the  vitri- 
form  body  of  Velpeau ;  it  adheres  more  intimately  to  the  amnion  than 
it  does  to  the  chorion. 


FIG.  74. 


Fro.  75. 


-PP 


e.  Embryo,  ec.  Cephalic  extremity,  eq. 
Caudal  extremity,  ca.  Amniotic  hood.  pp. 
Pleuro-peritoneal  cavity,  y.  Umbilical  vesicle. 


COMPLETION  OF  THE  AMNION. 
u.  Umbilical  vesicle,    p.  Pedicle  of  the  allan- 
toid.    a.  Amniotic  cavity. 


LIQUOR  AMNII.  The  amnial  liquor,  Fruchtwasser,  is  a  faintly  alka- 
line, serous  fluid,  having  a  specific  gravity  of  1002-1028  (Schroder), 
1002-1015  (Winckel).  It  is  at  first  transparent,  but  later  in  pregnancy 
becomes  somewhat  opaque  from  the  presence  of  lanugo,  epidermic  scales, 
and  particles  of  the  vernix  caseosa.  In  the  case  of  pregnant  women 
who  work  in  tobacco  factories  it  has  sometimes  been  found  greatly  dis- 
colored and  having  a  very  oifensive  odor ;  in  other  instances  this  fluid 
may  be  dark  green  or  brown  from  the  presence  of  meconium,  or  it  may 
be  reddish  if  the  foetus  has  been  dead  some  time  and  macerated. 
According  to  Robin,  it  sometimes  contains  epithelial  cells  from  the 
kidney  and  bladder,  and  leucocytes.  The  solid  ingredients  are  from  £ 
to  2  per  cent.  (Landois),  1  to  1.3  per  cent.  (Winckel).  Among  these 
are  the  chlorides  of  sodium,  potassium,  and  calcium,  lime  and  magnesium 
phosphates  and  sulphates,  sodium  and  potassium  sulphates,  and  sodium 
lactate,  creatin  and  creatinin,  albumin  and  mucosin,  and  urea.  Winckel 
states  that  at  first  the  quantity  seems  to  be  greater  than  the  weight  of 
the  embryo  :  Weight  of  ovum,  first  month,  0.8  gramme ;  liquor  amnii, 
0.42  gramme.  Weight  of  ovum,  second  month,  22.06  grammes  ;  liquor 
amnii,  15.3  grammes. 

About  the  middle  of  pregnancy  the  weight  of  the  amnial  liquor  is 
equal  to  that  of  the  foatus,  but  from  that  time  the  weight  of  the  latter 
exceeds,  though  the  quantity  of  the  former  still  increases,  according  to 
Gassner,  until  the  end  of  pregnancy,  then  amounting  to  1.87  kilo- 
grammes, although  Tarnier  asserts  that  if  the  quantity  exceeds  a  kilo- 
gramme the  condition  is  pathological.  Preyer  states  that  there  is  no 
relation  between  the  volume  and  size  of  the  placenta  and  the  quantity 
of  amnial  liquor,  nor  is  there  between  the  latter  and  spirals  of  the  cord  ; 


FCETAL  APPENDAGES.  127 

sheep,  for  example,  have  an  abundance  of  the  liquor,  though  in  them 
the  cord  is  scarcely  if  at  all  twisted. 

Questions  as  to  the  source  of  the  urea  and  the  significance  of  the 
albumin  in  the  amnial  fluid  will  be  considered  in  treating  of  the  func- 
tions and  nutrition  of  the  foetu?. 

ORIGIN  OF  THE  AMNIAL  LIQUOR.  It  has  beeu,  and  still  is,  claimed 
by  some  that  this  fluid  is  exclusively  a  foetal  product ;  but  the  experi- 
ments of  Krukenberg  first  proved  that  an  easily  diffusible  body  readily 
passed  from  the  bloodvessels  of  the  mother  into  the  amnial  liquid 
without  entering  the  foetal  blood.  It  is  generally  held,  as  was  stated 
by  Virchow  in  1850,  that  in  the  normal  state  the  mother  as  well  as  the 
foetus  takes  part  directly  in  the  formation  of  this  fluid.  It  has  also  been 
shown  that  iodide  of  potassium  introduced  into  the  amnial  fluid  may  be 
eliminated  through  the  mother;  that  in  the  case  of  the  hatching  egg  ot 
the  bird  there  is  an  amnial  fluid  which  must  necessarily  have  its  origin 
solely  from  the  embryo,  no  more  proves  that  this  is  the  exclusive  source 
in  viviparous  animals  than  the  presence  of  this  fluid  in  ectopic  gestation 
establishes  a  similar  truth.  The  skin  and  kidneys  of  the  foetus  and 
transudation  of  liquid  from  the  foetal  blood  through  the  amnion  con- 
tribute to  the  fluid,  but  its  chief  source1  is  the  maternal  bloodvessels. 

USES  OF  THE  AMNIAL  LIQUOR.  During  pregnancy  the  amnial 
liquor  preserves  the  foetus  and  the  vessels  of  the  cord  and  the  placenta 
from  mechanical  injuries,  facilitates  the  movements  of  the  foetus,  and 
permits  them  to  occur  with  less  inconvenience  or  suffering  to  the  mother ; 
gives  space  for  the  development  of  the  foetus,  prevents  adhesions  of 
amnion  and  foetus,  and  promotes  the  equable  enlargement  of  the  uterus. 
During  labor  it  protects  the  foetus  and  cord  from  injurious  pressure,  and 
furnishes  before  rupture  of  the  membranes  a  hydrostatic  dilator  for  the 
os  uteri,  while  after  rupture  the  escaping  fluid  lubricates  the  genital 
canal.  Further,  this  liquid  contributes  to  the  nutrition  of  the  foetus. 
Preyer2  states  that  in  the  foetus  the  tissues  contain  more  water  than  the 
blood,  and  it  must,  therefore,  get  water  from  some  other  source  than 
the  blood,  i.  e.,  from  the  amnial  fluid.  The  foetus  swallows  large  quan- 
tities of  amnial  fluid,  which  is  absorbed  by  blood  and  chyle  vessels  from 
the  intestinal  tract ;  in  the  early  stages  of  development  much  amnial 
fluid  enters  through  the  skin  of  the  embryo. 

THE  CHORION.  From  x6pt°»>  *ne  membrane  that  incloses  the  foetus 
in  the  womb.  This  membrane  is  external  to  the  amnion,  internal  to 
the  decidua.  At  the  beginning  of  intra-uterine  life  the  external  cover- 
ing of  the  ovum,  the  membrana  pellucida,  or  vitelline  membrane,  is 
transparent  and  smooth  ;  but  in  the  second  week  its  surface  presents 
numerous  projections,  called  villi,  which  are  at  first  solid,  and  this  is 
known  as  the  primitive  chorion.  The  permanent  chorion  is  formed  by 
the  junction  of  the  allantoid  and  subzonal  membranes,  followed  about 
the  fourth  week  by  bloodvessels  which  begin  to  penetrate  into  the  chorial 

1  This  is  the  statement  of  Winckel,  of  Veit,  and  many  others.    Bar,  however,  whose  thesis, 
Etude  clinique  du  liquide  amniotique  de  la  femme,  is  quoted  by  Ribemont-Dessaignes  and  Lepage 
(Precis  d'Obstetrique,  1893),  gives  only  the  foatal  origin.    A.  Martin  (Lehrbuch  der  Geburtshiilfe) 
says  "  the  origin  of  the  amnial  liquor  is  yet  in  dispute  ;  we  do  not  know  whether  it  is  a  product 
of  "the  foetus,  its  skin,  or  its  kidneys,  or  a  transudate  from  the  mother's  blood." 

2  Specielle  Physiologic  des  Embryo. 


128 


PHYSIOLOGY  OF  PREGNANCY. 


villi,  and  these  now  hollowed  out  become  sheaths  for  the  vessels ;  an 
artery  enters  each  villus  and  supplies  vessels  to  all  its  branches  or  bud- 
like  offshoots ;  capillaries  connect  with  veins,  and  the  latter  unite  in  a 
single  trunk  which  returns  the  blood  to  the  umbilical  veins. 


FIG.  76. 


FIG.  77. 


COMPOUND  VILLUS  OF  CHORION  FROM  A 
THREE  MONTHS'  FCETUS.  (Magnified 
30  diameters.) 


HUMAN  EMBRYO  AT  THE  THIRD  WEEK, 
SHOWING  VILLI  COVERING  THE  ENTIRE 
CHORION.  (HAECKEL.)  . 


At  first  all  the  chorial  villi,  thus  made  vascular,  hypertrophy,  but 
this  lasts  only  until  the  third  month,  when  those  villi  in  relation  with 
the  decidua  of  the  ovum,  the  decidua  reflexa,  atrophy,  while  those  con- 
nected with  the  serotine  decidua,  or  the  placental  decidua,  become  larger 
and  more  branched ;  the  portion  of  the  chorion  to  which  the  former 
belong  is  sometimes  spoken  of  as  the  chorion  leve  or  the  smooth  chorion, 
while  the  latter  is  called  the  chorion  frondosum  or  leafy  chorion.  The 
chorion  is  thicker  than  the  amnion,  but  is  weaker ;  it  is  composed  of 
two  layers,  one  chiefly  of  connective  tissue  becoming  fibrous  in  char- 
acter at  the  end  of  pregnancy,  and  the  other  of  pavement-epithelium. 
(See  Plate  I.) 

Doubtless  the  chorial  villi  even  before  they  become  vascular  are  con- 
cerned in  the  nutrition  of  the  embryo,  but  the  chief  use  of  the  chorion 
is  in  the  formation  of  the  placenta. 

In  the  accompanying  plate,  exhibiting  the  evolution  of  the  placenta 
and  of  the  umbilical  cord,  the  atrophy  of  the  larger  number  of  the 
chorial  villi,  and  the  hypertrophy  of  others,  those  which  contribute  to 
the  formation  of  the  placenta,  are  well  shown. 

THE  PLACENTA.  This  is  also  called  the  afterbirth.  The  name  pla- 
centa, from  irZaxovs,  a  flat  cake,  was  first  used  to  designate  this  organ  as 
found  in  the  human  female,  by  Realdus  Colombos.  In  many  of  the 
inferior  animals  its  form  is  very  different  from  that  signified  by  this  name. 
The  placenta  in  woman  is  a  fleshy,  flattened  mass,  usually  oval,  but  some- 
times round  or  reniform.  Its  diameter  is  six  to  eight  inches,  fifteen  to 


PLATE    I. 


EVOLUTION   OF  THE   PLACENTA   AND   OF   THE   UMBILICAL   CORD.       (From   SAPPEY.) 

1,1.    Embryo. 

2,  2,  2.    Amnion. 

3,  3,  3.    Cavity  of  Amnion 

i 

4,  4.    Digestive  Canal. 

5,  5    Pedicle  of  the  Umbilical  Vesicle. 

6,  Umbilical  Vesicle. 

7,  7.    Allantoid  Vesicle. 

8,  Pedicle  of  the  Allantois. 

9,  9,  9.    Chorial  Villi  beginning  to  atrophy. 

10,  10.    Villi  in  relation  with  the  utero-placental  decidua,  which  hypertrophy. 


[To  face  page  128. 


F(E  TA  L  A  P PEN  DA  GES. 


129 


twenty  centimetres;  it  is  thickest  at  the  insertion  of  the  cord,  varying 
from  a  little  more  than  one-third  to  more  than  an  inch,  one  to  three 
centimetres,  and  thinnest  at  the  margin,  where  its  thickness  is  about 
one-fifth  of  an  inch,  five  or  six  millimetres;  it  weighs  at  the  end  of 
pregnancy  about  eighteen  ounces,  or  five  hundred  grammes.  Never- 
theless there  is  great  variation  in  the  weight  of  the  placenta;  it  may  be 
only  one-half  that  given,  or  may  be  twice  as  much  ;  usually  the  weight 
is  in  direct  proportion  to  that  of  the  child. 

FIG.  78. 


FCETAL  SURFACE  OF  THE  PLACENTA. 

The  statement  last  made,  as  it  has  appeared  in  previous  editions,  having  been 
disputed,  in  one  of  my  visits  to  Munich  I  suggested  to  Dr.  J.  H.  Smith,  then 
acting  as  resident  obstetrician  in  the  Frauenklinik,  that  he  should,  with  such 
ample  material  there  available,  make  a  new  study  of  the  question.  He  did  so, 
and  from  the  history  of  500  cases  of  labor  prepared  an  elaborate  paper  which 
appeared  in  the  Journal  of  Gfynecology,  1891,  Toledo.  The  following  are  the 
most  important  conclusions  in  which  we  are  now  interested :  The  proportion  in 
weight  between  the  placenta  and  the  child  is  in  the  thirty-third,  and  thirty-fourth 
week  1:3;  in  the  thirty-fifth,  thirty-sixth,  and  thirty-seventh,  1:4;  thirty-eighth 
and  thirty-ninth,  1 : 5.  From  the  end  of  the  thirty-ninth  week  until  birth, 
whether  it  takes  place  in  the  fortieth  week,  or  delays  until  the  forty- fourth  week, 
the  ratio  is  1 : 5.  Dr.  Smith  also  stated,  as  a  result  of  his  investigations,  the  pla- 
centa seems  to  grow  in  delayed  labor  in  multiparae  or  with  large  children,  and 
then  the  average  rises  from  1 :  5  to  1 : 4. 

Winckel  states1  that  there  is  a  close  relation  between  the  weight  of  the  pla- 
centa and  that  of  the  child,  the  proportion  being  1 : 5.5.  Yet  in  the  case  of  a 
small  and  diseased  foetus  the  placenta  may  be  very  large  and  heavy. 

It  presents  two  faces  or  surfaces,  one  internal  or  fetal,  and  the  other 
external  or  maternal.  The  external,  or  uterine,  surface  of  the  placenta 
is  dark  red,  somewhat  convex,  rough  and  uneven.  It  presents  irregular 

1  Lehrbuch  der  Geburtshulfe,  second  edition,  1893. 
9 


130 


PHYSIOLOGY  OF  PREGNANCY 


fissures,  incompletely  dividing  the  organ  into  lobes ;  these  fissures  are 
partially  bridged  over  and  lined  by  a  whitish  membrane,  the  remains 
of  the  placental  or  serotine  decidua.  The  internal,  or  foetal,  surface  of 
the  placenta  is  smooth,  slightly  concave,  and  covered  by  the  combined 
chorion  and  amnion,  which  thus  form  its  superficial  layer ;  the  attach- 
ment of  the  cord  and  the  larger  divisions  of  its  placeutal  vessels  are 
plainly  seen.  A  large  vein,  called  the  circular  or  marginal  sinus,  is 
found  at  the  border  of  the  placenta.  In  some  cases  the  placenta,  instead 
of  being  a  single  mass,  is  composed  of  two  parts,  and  is  designated  as 
placenta  duplex  ;  if  composed  of  three  parts,  placenta  tripartita,  and  if 
of  many  separated  lobes,  placenta  multiloba ;  if  in  addition  to  the  usual 
placental  mass  there  should  be  one  or  more  distinct  and  separate  lobes, 
such  additional  placentae  are  called  subsidary  placentae,  or  placentce  sue- 
eenturiatce. 


FIG.  79. 


MATERNAL  SURFACE  OF  THE  PLACENTA. 

SITUATION  OF  THE  PLACENTA.  The  placenta  is  generally  in  the 
upper  part  of  the  uterus,  upon  the  posterior  or  upon  the  anterior  wall, 
in  the  vicinity  of  the  opening  of  one  of  the  oviducts. 

J.  Veit,  Muller's  Hamlbuch  der  Geburtshulfe,  first  volume,  makes  the  following 
statement :  Gusserow  in  188  cases  found  in  77  the  placenta  at  the  anterior  Avail, 
in  93  at  the  posterior  wall ;  12  at  the  right,  and  6  at  the  left;  Bidder,  139  women, 
73  on  the  posterior  wall,  53  anterior,  and  in  8  at  the  fundus ;  while  Schrader  gives 
the  situation  of  the  placenta  37  times  in  front,  18  times  behind,  1  directly  right, 
8  right  and  in  front,  7  right  and  behind,  and  2  left  and  in  front. 


FCETAL  APPENDAGES. 


131 


Attachment  directly  to  the  fundus — once  regarded  as  frequent,  if  not 
the  rule — is  as  rare  as  is  that  to  the  lower  part  of  the  uterus.1  But,  as 
remarked  by  Levret,  "  there  is  not  a  single  part  of  the  interior  of  the 
womb  where  the  placenta  may  not  take  root."  When  the  attachment 
is  in  the  lower  uterine  segment  the  placenta  is  called  prtevia.  After 
the  delivery  of  the  placenta  the  obstetrican  can,  by  noticing  the  place  of 
rupture  of  the  membranes,  judge,  approximately  at  least,  the  place 
which  the  organ  occupied  in  the  womb. 


FIG.  80. 


SECTION  OF  A  PORTION  OF  A  FULLY  FORMED  PLACENTA,  WITH  THE  PART  OF  THE  UTERUS 

TO  WHICH  IT  IS  ATTACHED. 

a.  Umbilical  cord.    6,  b.  Section  of  uterus,  showing  the  venous  sinuses,    o,  o.  Branches  of 
the  umbilical  vessels,    d,  d.  Curling  arteries  of  the  uterus. 

It  is  not  until  in  the  third  month  of  pregnancy  that  the  placenta 
begins  to  be  distinct,  and  it  is  not  until  the  end  of  the  month  that  its 
formation  is  completed.  Part  of  this  organ  is  of  maternal  and  part  of 
foetal  origin,  but  these  parts  become  so  intimately  united  that  they  can 
only  be  separated  in  an  early  stage  of  its  development.  The  placenta 
increases  in  weight  until  about  the  seventh  month,  when  a  regressive 
metamorphosis  begins.  The  large  villi  of  the  chorion  frondosum  pene- 
trate into  the  tissue  of  the  decidua  of  the  serotina ;  they  do  not  enter 
the  uterine  glands,  but  into  crypts  formed  by  the  hypertrophied  uterine 
mucous  membrane ;  the  villi,  at  first  comparatively  simple  in  form,  not 
only  greatly  increase  in  size,  but  in  number ;  they  become  complex, 
presenting  many  branches  and  offshoots.  Goodsir  has  compared  a 
placental  tuft  to  a  tree,  consisting  of  a  trunk  with  its  primary  and 
secondary  branches.  Meantime  the  villi  of  the  chorion  not  in  relation 

i  Carmichael  (Dublin  Journal  of  Medical  Science,  1839)  having  concluded,  from  his  own  ex- 
aminations, that  the  usual  site  of  the  placenta  was  the  lower  part  of  the  posterior  uterine  wall, 
caused  so  much  controversy  by  the  statement  that  he  pleasantly  remarked  if  he  had  anticipated 
such  a  result  he  would  have  left  the  placenta  at  the  fundus. 


132 


PHYSIOLOGY  OF  PREGNANCY. 


with  the  membrana  serotina  atrophy,  and  thus  the  chorion  leve  results. 
The  villi  of  the  chorion  froudosuin  are  formed  of  connective  tissue,  and 
also,  as  stated  by  Goodsir  and  confirmed  by  subsequent  observers,  re- 
ceive an  epithelial  covering  from  the  hypertrophied  serotiue  membrane. 
Each  villus  then  is  composed  of  connective  tissue,  of  an  epithelial  cover- 
ing, and  of  an  artery  and  vein  and  connecting  capillaries ;  this  arrange- 
ment of  the  bloodvessels  secures  a  closed  vascular  system.  The  placenta 
is  composed  of  the  hypertrophied  villi  of  the-chorion  and  of  the  serotine 
decidua,  which  grow  into  each  other,  mutually  inter-penetrating,  so  that 
a  single  mass  is  formed. 

After  the  interlocking  of  the  chorial  villi  with  the  serotine  membrane 
blood-spaces  or  sinuses  are  found  in  the  maternal  portion  of  the  placenta. 
This  results,  according  to  some,  from  great  dilatation  of  the  maternal 
capillaries,  but  according  to  others  from  disappearance  of  the  walls  of 
the  capillaries,  caused  by  the  pressure  of  the  growing  chorial  villi.  Into 
these  spaces,1  these  blood-lakes,  maternal  arteries2  enter,  and  from  them 
veins  issue.  The  terminal  villi  of  the  chorion  float  freely  in  the  blood- 
sinuses,  and  thus  the  maternal  is  brought  into  such  close  relation  with 
the  fetal  blood  that  interchange  of  gases  and  nutritive  materials  can 
readily  occur. 

FIG.  81. 


VERTICAL  SECTION  OF  PLACENTA,  SHOWING  RELATIONS  OF  MATERNAL  AND  FCETAL  BLOODVESSELS. 
a,  a.  Chorion     6, 6.  Decidua.    c,  c,  c,  c.  Orifices  of  uterine  sinuses. 

USES  OF  THE  PLACENTA.  The  placenta  is  the  organ  of  nutrition 
and  of  respiration  for  the  foetus.  It  was  once  held  that  there  was  a 
direct  communication  between  the  bloodvessels  of  the  mother  and  the 
foetus  through  the  placenta,  and  thus  the  nutrition  of  the  foetus  was 

1  Braxton  Hicks  (London  Obstetrical  Society's  Transactions,  vol.  xiv.)  denies  the  existence  of 
placental  sinuses,  stating  that  from  dissections  early  and  late  in  pregnancy  there  is  no  evidence 
of  a  sinus  system. 

2  Delore  (Annales  de  Gynecologic,  1874)  contends  that  the  entrance  of  maternal  blood  into  the 
placenta  is  chiefly  by  the  placental  coronary,  or  circular  sinus,  which  was  first  described  by 
Meckel,  and  which  sometimes  has  a  diameter  as  large  as  the  little  finger. 


FCETAL  APPENDAGES.  133 

explained.  This  view  is  disproved  by  the  following  facts  :  The  maternal 
and  the  foetal  circulation  are  not  isochronous ;  prior  to  the  extension  of 
the  allantoid  vessels  to  the  periphery  of  the  ovum  the  embryo  had  a 
circulation ;  if  the  foetus  die  in  labor  when  the  mother  perishes  from 
hemorrhage,  it  dies  from  asphyxia,  not  from  anemia.  If  the  placenta 
be  delivered  with  the  foetus,  the  circulation  may  continue  several  min- 
utes, and  there  is  no  discharge  of  blood  from  the  uterine  surface  of  the 
placenta ;  if  hemorrhage  from  the  umbilical  cord  occur  during  labor,  it 
does  not  affect  the  mother ;  the  foetal  blood  differs  from  the  maternal 
blood  in  the  form  of  the  globules  and  in  its  composition.  It  is  gen- 
erally held  that  the  interchange  of  gases  and  of  nutritive  elements 
between  the  maternal  and  the  foetal  blood  depends  upon  osmosis.1  Ac- 
cording to  Marchal,  the  endosmotic  processes  by  which  nutritive  juices 
pass  from  the  mother  to  the  foetus  are  facilitated  by  the  greater  blood- 
pressure  in  the  vessels  of  the  former  than  iu  those  of  the  latter.  Ex- 
periments show  that  substances  in  solution  may  pass  from  the  maternal 
to  the  foetal  blood.  Among  such  substances  are  potassic  iodide,  salicylic 
acid,  chloroform,  chlorides,  and  turpentine.  Many  years  ago  Magendie 
detected  the  odor  of  camphor  in  the  blood  of  the  foetus  fifteen  minutes 
after  a  solution  of  this  substance  had  been  injected  into  the  maternal 
blood.  Recent  experiments,  among  others  those  of  Dr.  Pyle,2  prove 
that  some  undissolved  substances  and  bacteria  may  thus  pass  from  the 
mother  to  the  foetus.  Several  other  observers,  both  before  and  since  Dr. 
Pyle's  experiments,  have  arrived  at  the  same  results.  The  passage  of 
microbes  through  the  placenta  to  the  foetus  is  not  a  constant  fact,  and 
when  it  occurs  the  explanation  given  is  that  these  microbes  have  first 
produced  placental  lesions  permitting  their  migration. 

That  the  placenta  is  the  organ  of  respiration  for  the  foetus  is  shown  by 
the  fact  that  the  blood  going  to  the  placenta  is  dark,  and  that  returning 
from  it  light;  and  that  the  only  substitute  for  placental  is  pulmonary 
respiration.  If  the  umbilical  circulation  be  arrested,  the  foetus  dies,  and 
an  autopsy  proves  the  death  was  from  asphyxia.  In  the  placenta  the 
foetus  exchanges  carbonic  acid  for  oxygen,  just  as  a  fish  through  its  gills 
receives  oxygen  from  the  water  in  which  it  swims.  Bernard  has  shown 
that  the  placenta  has  a  glycogenic  function  in  the  earlier  months  of 

1  Ercolani  taught  that  the  foetal  portion  of  the  placenta  is  vascular,  or  absorbent,  and  the 
maternal  is  glandular,  or  secretory.    According  to  his  theory,  the  uterine  juices,  OP  milk,  secreted 
by  the  epithelium  of  the  latter,  are  absorbed  in  the  chorial  vllli,  as  chyle  is  absorbed  by  the  intes- 
tinal villi.    Balfour  has  given  a  qualified  and  partial  support  to  this  view,  saying  :  "  The  walls  of 
the  crypts  into  which  the  villi  are  fitted  also  become  highly  vascular,  and  a  nutritive  fluid  passes 
from  the  maternal  vessels  of  the  placenta  to  the  foetal  vessels  by  a  process  of  diffusion ;  while 
there  is  probably  also  a  secretion  by  the  epithelial  lining  of  the  walls  of  the  crypts,  which  becomes 
absorbed  by  the  vessels  of  the  foetal  villi."    Goodsir  stated  that  the  function  of  the  placenta  is  not 
only  that  of  a  lung,  but  also  of  an  intestinal  tube,  and  that  the  internal  cells  of  the  villi  absorb  the 
matter  secreted  by  the  external  cells.    Kormann  (Lehrbuch  der  Geburtshiilfe,  1884)  states  that  the 
nutritive  material  which  the  foetus  finds  prepared  in  the  placenta  is  the  so-called  uterine  milk. 
According  to  Hoffman  (Berlin.  Zeitschr.  f.  Geb.  und  Gyn.,  1882),  the  purpose  of  the  decidua  in  man 
as  well  as  in  animals  is  to  furnish  the  necessary  nourishment  of  the  young.    The  decidua  is  a  milk- 
secreting  organ  ;  this  milk,  which  is  secreted  into  the  spaces  which  are  gradually  formed,  and  in 
which  the  placental  villi  are  placed,  here  is  mixed  with  the  simultaneously  extravasated  blood  of 
the  mother,  and  thus  the  foetal  nourishment  is  formed  which  is  absorbed  by  the  placental  villi. 
Landois  (Manual  of  Human  Physiology)  states :  "Between  the  villi  of  the  placenta  there  is  a  clear 
fluid  which  contains  numerous  small  albuminous  globules,  and  this  fluid,  which  is  abundant  in 
the  cow,  is  spoken  of  as  the  uterine  milk.    It  seems  to  be  formed  by  the  breaking  up  of  the  decidual 
cells.    It  has  been  supposed  to  be  nutritive  in  function."    Stirling  adds,  that  the  maternal  placenta, 
therefore,  seems  to  be  a  secretorv  structure,  while  the  foetal  part  has  an  absorbing  function.    The 
uterine  milk  has  been  analyzed  by  Gamgee,  who  found  that  it  contained  fatty,  albuminous,  and 
saline  constituents,  while  sugar  and  casein  were  absent. 

2  Philadelphia  Medical  Times,  June  and  July,  1884. 


134 


PHYSIOLOGY  OF  PREGNANCY. 


foetal  life,  prior  to  the  formation  of  the  liver.  Foster  suggests  that  the 
placental  glycogeu  is  of  use,  not  for  the  fcetus,  but  for  the  nutrition  and 
growth  of  the  placental  structures. 

THE  UMBILICAL  CORD.  The  funis  umbilicatus,  or  umbilical  cord, 
receives  its  name  from  its  twisted  character.  It  is  a  cord,  essentially 
composed  of  bloodvessels,  connecting  the  fcetus  and  the  placenta.  The 
pedicle  of  the  allantoid,  originally  a  constricted  portion  connecting  the 
two  portions  of  the  allautoid,  one  within  the  embryo,  the  other  external 
to  it,  is  the  beginning  of  the  umbilical  cord.  At  first,  this  pedicle  or 
stalk  had  two  veins  as  well  as  two  arteries  ;  one  of  the  veins,  however, 
atrophies,  so  that  the  cord  has  one  vein  and  two  arteries.  Hyrtl  found 
in  6  per  cent,  of  cases  only  one  umbilical  artery. 

FIG.  82. 


A.  Umbilical  arteries  forming  spirals  (1,  1')  around  the  vein ;  constrictions  indicating  the 
presence  of  folds  (5,  5') ;  lateral  openings  showing  the  arterial  walls.  B.  Vein  opened  upon  the 
side,  showing  a  constriction  (2)  corresponding  to  an  interior  valve  (3") ;  semilunar  valves  (3,  3',  3"). 
C.  Section  of  vein  and  arteries,  showing  valve  of  vein  (1),  a  semilunar  arterial  valve  (2),  and  a 
circular  arterial  valve  (3).  (TAENIER  ET  CHANTREUIL.) 

The  formation  of  the  cord  begins  at  the  end  of  the  fourth  week.  At 
the  middle  of  pregnancy  its  length  is  5  to  8  inches,  13  to  21  centimetres, 
and  its  thickness  about  one-third  of  an  inch ;  at  the  end  of  pregnancy 
its  average  length  is  about  20  inches,  50  centimetres,  and  its  usual 
thickness  that  of  a  man's  little  finger.  But  the  thickness  may  be  much 
greater,  equalling  that  of  the  thumb,  or  even  exceeding  it ;  if  thus  in- 
creased in  size,  it  is  commonly  called  a  u  fat  cord,"  while  if  its  diameter 
is  notably  lessened,  it  is  called  a  "  lean  cord."  The  length  of  the  cord 
may  be  reduced  to  two  inches,  or  increased  to  five  or  six  times  the 
average  previously  given.  Its  surface  is  smooth  and  shining  from  its 
amniotic  investment;  it  presents  a  twisted  or  spiral  aspect ;  the  number 
of  spirals  varies ;  in  one  case  Meckel  saw  ninety-five :  the  largest  number 
of  torsions,  however,  occurred  in  a  case  observed  by  Schauta,  380.  The 
spirals  in  the  majority  of  cases  turn  to  the  left,  and  thus  Auvard,1  com- 

1  Op.  cit. 


FCETAL  APPENDAGES. 


135 


bluing  the  results  obtained  by  Neugabauer,  Hecker,  aud  Tarnier  with  his 
own,  found  that  there  was  sinistrotorsion  in  533,  dextrotorsion  in  190,  tor- 
sion in  opposite  directions  in  4,  aud  entire  absence  of  torsion  in  17,  the  total 
number  being  744.  The  movements  of  the  foetus  which  produce  torsion 
of  the  cord  begin  very  early,  for  when  the  embryo  was  only  one  inch 
long  the  cord  was  somewhat  twisted ;  according  to  Preyer,  torsion  of 
the  cord  uniformly  commences  in  the  eighth  week.  In  most  instances 
the  vein  is  central,  aud  the  arteries  turn  round  it ;  but  in  others,  all 
three  of  the  vessels  are  parallel,  aud  turn  round  a  fictitious  axis.  Why 
the  torsions  begin  and  are  more  numerous  in  the  vicinity  of  the  umbilicus 
must  be  obvious  to  anyone  who  watches  twisting  two  threads  by  the 
finger  and  thumb  at  one  end,  the  other  being  fixed.  The  torsions  of 
the  cord  are  caused  by  foetal  movements,  and  of  course  must  first  appear 
nearest  the  moving  body. 

FIG.  83. 


TWISTED  CORD.    (From  SCHAUTA.) 

The  amuial  sheath  not  only  incloses  the  vein  and  arteries,  but  also  a 
greater  or  less  quantity  of  a  gelatinous  substance  called  Wharton's  jelly. 
An  unusual  quantity  of  this  material  causes  the  cord  to  be  very  thick, 
and  when  it  is  tied  after  birth  there  is  great  liability  to  subsequent 
hemorrhage  unless  the  tying  be  done  very  carefully  so  that  complete 
constriction  of  the  bloodvessels  is  secured.  Wharton's  jelly  is  a  gelat- 
inous-like  connective  tissue,  consisting  of  branched  corpuscles,  lymphoid 
cells,  some  connective-tissue  fibres,  and  elastic  fibres.  Accumulations 
of  the  jelly  at  particular  parts  of  the  cord,  making  decided  prominences, 
cause  what  have  been  called  false  knots.  But  the  absence  of  the  jelly 
at  a  part  of  the  cord  does  not  prove  that  any  of  the  vessels  are  imper- 
vious, or  even  that  their  capacity  is  lessened.1  The  vein  has  a  thinner 

1  The  illustration,  Fig.  84,  represents  the  appearance  of  the  ftetal  end  of  the  umbilical  cord  in  a 
large,  seven  months'  stillborn  foetus.    The  foetus  was  brought  to  me  as  showing  intra-uterine  death 


136  PHYSIOLOGY  OF  PREGNANCY. 

>  wall  than  the  arteries ;  the  diameter  of  its  canal  is  greater  than  that  of 
either  artery,  and  increases  as  the  vessel  approaches  the  foetus ;  from  the 
inner  surface  of  the  vein  crescent-shaped  folds  project,  occluding  two- 
thirds  of  the  canal.  The  arteries  widen  in  the  course  of  the  cord  from 
the  foetus  to  the  placenta,  and  have  projecting  broad  folds.  The  vessels 
have  well-developed  muscular  walls,  and  hence  are  very  contractile. 

FIG.  84. 


APPARENT  CONSTRICTION  OP  BLOODVESSELS  OP  CORD,  FROM  ABSENCE  OP  WHARTON'S  JELLY. 

According  to  Kleinwachter,  the  cord  has  lymphatics,  and  Ruyl  claims 
that  he  discovered  nutritive  capillaries  in  it.  Winckel  remarks  that 
Valentine,  Schott,  and  Kolliker  described  nerves  and  lymphatics  in  the 
cord,  but  these  were  not  found  by  Virchow. 

The  strength  of  the  umbilical  cord  varies,  and  in  some  cases  very 
slight  traction  causes  its  rupture.  Duncan  and  Turnbull  have  from 
experiments1  concluded  that  the  average  weight  required  to  break  the 
cord  is  eight  and  one-quarter  pounds ;  the  weakest  is  torn  by  five  and 
one-half  pounds,  and  the  strongest  fifteen  pounds.  Pfannkuch  has 
shown  that  a  varicose  cord  has  little  more  than  half  the  strength  of  one 
with  its  vessels  normal. 

True  knots  are  sometimes  found  in  the  cord.  They  have  been 
attributed  to  the  violent  movements  of  the  foetus,  favored  by  excess  of 
liquor  amnii,  and  to  similar  movements  of  the  mother ;  it  is  altogether 
exceptional  for  knots,  however  numerous,  to  interrupt  the  circulation. 

«* 

from  obstruction  of  the  umbilical  vessels ;  injections,  however,  proved  that  they  were  not  only 
pervious,  but  of  normal  calibre.  Dr.  James  Young  (Transactions  of  the  Edinburgh  Obstetrical 
Society,  Edinburgh,  1870)  has  reported  a  similar  case,  a  dead  fcetus  at  seven  months  being  expelled  ; 
the  umbilical  cord  was  "  greatly  constricted  near  the  abdomen  ;"  but  the  just  test  of  constriction 
involving  the  bloodvessels  was  not  made. 
1  London  Obstetrical  Society's  Transactions,  vol.  xxiii. 


FCETAL  APPENDAGES.  137 

The  attachment  of  the  cord  to  the  placenta  is  usually  at  some  point 
between  the  centre  and  the  margin  ;  the  central  insertion,  though  by 
some  authorities  claimed  to  be  the  rule,  Naegele  correctly  stated  is  rela- 
tively rare  ;  Levret  made  a  similar  statement.  In  some  cases  the  cord 
is  attached  to  the  margin  of  the  placenta,  insertio  marginalia,  and  the 
placenta  is  called  battledore  placenta;  in  one  variety  of  marginal  inser- 
tion the  cord  is  attached  first  to  the  membranes  and  the  vessels  subdi- 

FIG.  85. 


VELAMENTOUS  INSERTION  OF  THE  CORD. 

vide  before  entering  the  substance  of  the  placenta/  insertio  velamentosa 
(see  Fig.  85).  Velamentous  insertion  occurs  in  nearly  one  per  cent,  of 
cases.  Auvard  states  that  the  insertion  may  be  twenty  centimetres 
from  the  placental  margin'.  In  some  cases  the  vessels  divide  into 
branches  before  reaching  the  placenta,  but  in  others  they  continue 
undivided  to  it.  The  dangers  from  this  anomaly  in  labor  are  pressure 
upon  the  vessels,  causing  asphyxia  of  the  child,  or  rupture  when  the 
membranes  rupture,  causing  hemorrhage. 

The  insertion  of  the  cord,2  observed  by  Cre'de  in  443  cases,  was  in 
109  central,  in  164  excentric,  in  152  near  the  margin  of  the  placenta,  in 
8  at  the  margin,  and  in  10  velamentous. 

1  Lugol,  Journ.  de  Med.  du  Bordeaux,  June,  1889,  has  reported  a  case  of  single  pregnancy,  the 
insertion  of  the  cord  relamentous,  the  placenta  being  double— the  two  parts,  which  were  nearly 
equal,  were  three  to  four  centimetres  apart. 

*  Lehrbuch  der  Geburtshitlfe. 


CHAPTER  Y. 

THE   EMBRYO   AND   FCETUS — DEVELOPMENT — ANATOMY  AND   PHYSI- 
OLOGY  OF   THE   FCETUS — PLURAL   PREGNANCY. 

THE  term  foetus,  a  Latin  word  for  the  young  of  mammiferae  while  in 
the  womb,  is  very  commonly  used  as  a  synonym  for  embryo,  the  etymo- 
logical signification  of  which  has  been  stated.  By  many,  however,  the 
product  of  conception  in  the  human  female  is  called  an  embryo  up  to 
three  months,  and  after  that  it  is  known  as  a  fetus.  This  distinction 
between  the  two  words  is  plainly  arbitrary,  and  as  far  as  the  term 
embryo  is  concerned,  is  disregarded  in  such  words  as  embryotomy  and 
embryulcia.  Nevertheless,  as  the  history  of  the  first  three  months 
differs  very  materially  from  that  of  the  subsequent  six  of  intra-uterine 
life,  since  by  the  end  of  three  months  the  placenta  is  formed,  and  the 
new  being  has  assumed  the  human  form,  and  subsequent  changes  are  of 
growth  and  development  rather  than  of  the  beginning  of  organs 
belonging  to  the  organism  and  essential  for  its  existence  or  for  its 
perpetuation,  it  is  well  to  retain  the  arbitrary  distinction  between  the 
words  embryo  aud  foetus. 

Naegele  said  that  the  obstetrician  was  more  concerned  with  expe- 
dition than  with  fabrication — that  is,  with  labor  rather  than  with 
embryology ;  nevertheless,  some  study  should  be  given  to  the  latter. 
While,  of  course,  embryology  belongs  to  physiology,  and  is  there  fully 
presented,  yet  a  general  knowledge  of  the  evolution  of  the  new  being 
from  the  fecundated  ovule,  "the  dim  speck  of  entity,"  belongs  to 
obstetrics.  Such  knowledge  is  practically  useful  in  that  it  enables  the 
obstetrician  to  recognize  how  far  development  has  progressed  in  a  case 
of  miscarriage ;  in  some  cases  to  ascertain  the  cause  of  miscarriage, 
whether  the  miscarriage  be  embryonic  or  foetal,  and  also  to  explain  the 
occurrence  of  certain  deformities  or  so-called  malformations,  which  are 
in  most  cases  arrests  of  formation,  failures  of  development.  This  knowl- 
edge, too,  is  of  value  in  studying  the  physiology  of  the  foetus.  In  the 
following  summary  sketch  of  embryonic  and  foetal  development  no 
attempt  will  be  made  to  include  all  details  and  make  a  complete  picture, 
but  chiefly  to  present  practical  matters  of  interest  and  importance  to 
the  obstetrician. 

FIRST  MONTH.  Recalling  the  statement  made  on  page  121,  as  to 
the  formation  of  the  blastodermic  vesicle,  its  separation  into  two  por- 
tions, one  embryonic,  the  other  non-embryonic,  and  the  appearance  in 
the  former  of  the  medullary  groove,  with  a  fold  or  plate  on  each  side, 
lamince  dorsales,  the  two  subsequently  uniting,  so  that  the  groove  is 
converted  into  a  cylindrical  canal — the  medullary  canal — it  is  S€-en  that 
in  the  very  beginning  of  organization  the  nervous  system  is  placed  first. 
The  heart,  at  first  a  tubular  cavity,  is  seen  by  the  end  of  the  second 


THE  EMBRYO  AND  FCETUS.  139 

week,1  when  the  embryo  is  only  one-eighteenth  of  an  inch,  two  milli- 
metres, long ;  by  the  middle  of  the  third  week  it  has  taken  an  S  form  ; 
and  at  the  end  of  the  fourth  the  different  cavities  are  present  and  the 
pericardium  is  formed.  According  to  Preyer,2  it  cannot  be  doubted 
that  the  heart  commences  to  beat  by  the  beginning  of  the  third  week. 
The  visceral  clefts,  four  in  number,  and  arches  are  apparent  by  the 
twentieth  day  ;  the  former  are  fissures  found  on  each  side  of  the  cervical 
region,  while  the  arches  are  thickenings  of  the  lateral  walls  between  the 
clefts.  „ 

FIG.  86. 


an 

SCHEME  OF  A  HUMAN  EMBRYO  WITH  THE  VISCERAL  ARCHES  STILL  PERSISTENT. 
A.  Amnion.  V.  Fore-brain.  M.  Mid-brain.  H.  Hind-brain.  N.  After-brain.  U.  Primitive 
vertebrae,  a.  Eye.  p.  Nasal  pits.  S.  Frontal  process,  y.  Internal  nasal  process,  n.  External 
nasal  process,  r.  Superior  maxillary  process  of  the  first  visceral  arch.  1,  2,  3,  and  4.  The  four 
visceral  arches,  with  the  visceral  clefts  between  them.  o.  Auditory  vesicle,  h.  Heart,  with  e, 
primitive  aorta,  which  divides  into  five  aortic  branches.  /.  Descending  aorta,  om.  Omphalo- 
mesenteric  artery,  b.  The  omphalo-mesenteric  arteries  on  the  umbilical  vesicle,  c.  Omphalo- 
mesenteric  vein.  L.  Liver  with  arriving  and  departing  veins.  D.  Intestine,  i.  Inferior  cava 
T.  Coccyx,  all.  Allantois,  with  Z,  one  umbilical  artery ;  and  x,  an  umbilical  vein.  B.  Umbilical 
vesicle. 

The  extremities  appear  at  the  sides  of  the  body  as  short  uujointed 
stumps  or  projections  in  the  third  or  fourth  week.  At  the  end  of  the 
fourth  week  the  vertebral  bodies  and  the  nerve  centres  are  quite  distinct, 
the  thorax  and  abdomen  make  a  single  cavity,  the  diaphragm  not  yet 
having  been  formed,  and  the  heart  is  in  the  upper  part  of  this  cavity. 
The  ovum  is  about  the  size  of  a  pigeon's  egg.  The  embryo  is  a  grayish 
curved  mass,  the  cephalic  end  is  much  larger  than  the  caudal,  and  so 
great  is  the  curvature  that  the  two  approach  ;  the  length  of  the  embryo 

1  Aristotle  stated  that  the  heart  could  sometimes  be  seen  in  the  bird's  egg  as  early  as  the  third 
day,  no  bigger  than  a  point ;  it  is  compared  to  a  bloody  spot,  and  its  beating  is  mentioned  ;  from 
bis  description  the  punctum  saliens  of  later  writers  is  derived.    The  heart  is  the  first  of  organs  not 
in  formation,  but  in  function,  and  in  this  sense  is  indeed  primum  vivens,  though  not  in  all  cases 
ultimum  moriens.    Modern  observers  know  that  the  heart  in  the  chick  is  at  the  end  of  the  first  day 
"  a  small,  bright-red,  contracting  point."    Its  development  in  mammals  is  much  later. 

2  Op.  cit. 


140  PHYSIOLOGY  OF  PREGNANCY. 

is  about  half  an  inch,  or  thirteen  millimetres.  The  primitive  intestine 
is  a  straight  tube,  proceeding  from  the  head  to  the  tail,  and  closed  at 
each  end.  It  was  at  first  a  gutter,  and  had  free  communication  with 
the  vitelline  sac  ;  but  the  gutter  is  covered  over,  and  is  converted  into  a 
cylindrical  canal,  and  the  vitelline  duct,  inserted  at  that  point  which  at 
a  later  period  corresponds  to  the  lower  part  of  the  ileum,  is  obliterated. 
In  some  cases  the  duct  remains  pervious  a  short  distance  from  the 
intestine,1  making  a  blind  tube,  the  so-called  "true  intestinal  diverticu- 
lum ;"  in  very  rare  cases  the  duct  may  remain  open  to  the  umbilicus, 
forming  a  congenital  fistula  of  the  ileum,  or  it  may  give  rise  to  cystic 
formations. 


FORMATION  OF  ALIMENTARY  CANAL. 

a  b.  Commencement  of  amnion.     c  c.  Intestine.   /.  Allantols.    g.  Umbilical  vesicle,    e.  Dotted 
line  showing  the  place  of  the  formation  of  the  oesophagus. 

Kolliker  divides  the  primitive  intestine  into  three  segments — the 
buccal,  middle,  and  terminal.  From  the  buccal,  or  initial,  segment  all 
the  buccal  cavity  as  far  as  the  glosso-palatine  arches  is  derived  ;  the 
terminal  portion  furnishes  the  lower  portion  of  the  cloaca ;  while  all  the 
rest  of  the  intestinal  canal  and  a  notable  part  of  the  uro-genital  system 
are  derived  from  the  middle  segment.  About  the  fourth  week  a  depres- 
sion upon  the  external  tegument  occurs  at  a  point  corresponding  with 
the  lower  end  of  the  terminal  segment,  with  absorption  of  intervening 
tissue,  and  the  anus  is  formed.  A  similar  depression  of  the  tegument 
occurs  at  a  point  corresponding  with  the  position  to  be  occupied  by  the 
mouth,  and  an  opening  is  made  which  communicates  with  the  buccal 
portion  of  the  intestine ;  the  mouth  at  first  represents  the  space  com- 
prised between  the  first  visceral  arch  and  the  most  anterior  part  of  the 
base  of  the  cranium. 

SECOND  MONTH.  During  this  month  the  visceral  clefts  completely 
close  except  the  first,  which  becomes  the  external  auditory  meatus,  the 
cavity  of  the  tympanum,  and  the  Eustachian  tube.  "  Should  any  of 
the  other  clefts  remain  open,  a  condition  that  is  sometimes  hereditary 
in  some  families,  a  cervical  fistula  results,  and  it  may  be  formed  either 

1  Landois. 


THE  EMBRYO  AND  FCETUS.  141 

from  without  or  within.  Branchiogenic  tumors  and  cysts  depend  upon 
the  branchial  arches,  according  to  Volkmaun. 

The  first  visceral  or  branchial  arch  divides  into  two  branches  called 
the  superior  and  the  inferior  maxillary  processes  ;  the  two  inferior  maxil- 
lary processes,  one  from  each  side,  grow  toward  each  other,  meet,  and 
unite,  making  the  lower  margin  of  the  mouth.  So,  too,  the  superior 
maxillary  processes  grow  toward  each  other,  but  there  intervenes  the 
frontal  process  (S,  Fig.  86),  which  unites  with  each  of  the  others,  and 
thus  the  upper  boundary  of  the  mouth  is  made,  and  the  oral  separated 
from  the  nasal  opening.  The  separation  between  the  nose  and  mouth 
within  is  made  by  the  superior  maxillary  processes;  from  these  the 
upper  jaw,  the  nasal,  and  the  intermaxillary  process  are  produced;  at 
the  ninth  week  the  hard  palate  is  closed;  upon  it  rests  the  septum  of 
the  nose,  descending  vertically  from  the  frontal  process.  Different 
varieties  of  harelip  result  from  arrest  of  descent  of  the  frontal  process, 
or  from  its  failure  to  unite  upon  one  or  upon  both  sides  with  the  supe- 
rior maxillary  processes. 

It  not  unseldom  happens,  that  if  an  infant  be  born  with  harelip,  the 
mother  attributes  the  deformity  to  her  having  seen  while  she  was  preg- 
nant some  one,  adult  or  child,  similarly  affected.  But  if  she  saw  such 
an  object  subsequent  to  the  second  month  of  pregnancy,  it  is  impossible 
that  the  foetus  could  have  been  affected  through  her  mind,  for  the  de- 
formity already  existed. 

Cleft  palate  arises  from  the  failure  of  those  portions  of  the  superior 
maxillary  processes  concerned  in  the  formation  of  the  roof  of  the  mouth 
to  meet  and  unite.  As  is  seen,  the  formation  of  the  face  chiefly  results 
from  the  development  of  the  first  or  maxillary  arches.  The  second 
arch,  hyoid,  gives  rise  to  the  stapes,  the  pyramidal  eminences,  with  the 
stapedius  muscle,  the  styloid  process  of  the  temporal  bone,  the  stylo- 
hyoid  ligament,  the  smaller  cornu  of  the  hyoid  bone,  and  the  glosso- 
palatine  arch.  The  third  arch,  thyro-hyoid,  forms  the  greater  cornu  and 
body  of  the  hyoid  bone  and  the  pharyngo-palatine  arch.  The  fourth 
arch  gives  rise  to  the  thyroid  cartilage. 

In  the  second  month  the  eyes  appear  first  as  two  black  points,  one 
on  each  side  of  the  head ;  the  eyelids  are  not  seen  until  the  latter  part 
of  the  month  or  the  beginning  of  the  next.  The  external  ear  appears 
as  a  slight  projection  at  the  seventh  week.  From  development  of 
the  viscera  the  body  becomes  less  curved.  The  Wolffian  bodies  are 
notably  lessened  in  size,  but  meantime  the  kidneys  and  supra-renal 
capsules  are  formed.  The  fingers  and  toes  appear,  but  they  are  webbed. 
The  formation  of  the  external  sexual  organs  begins,  as  previously  stated, 
in  the  sixth  week,  but  they  present  the  same  appearance  in  each  sex ; 
the  testicles  or  the  ovaries  appear  about  the  seventh  week.  At  the  end 
of  the  second  month  the  ovum  is  about  the  size  of  a  hen's  egg ;  the 
embryo  measures  from  one  inch  to  one  inch  and  a  half,  twenty-five  and 
a  half  to  thirty-seven  millimetres,  in  length,  and  weighs  about  one 
drachm,  four  grammes ;  the  umbilical  cord  measures  a  little  more  than 
one  inch,  twenty-five  and  a  half  millimetres. 

THIRD  MONTH.  The  fingers  and  toes  have  lost  their  webbed  char- 
acter, and  the  nails  begin  to  be  developed,  appearing  as  fine  membranes. 


1 42  PHYSIOLOG Y  OF  PREGNANCY. 

The  eyes  are  nearer,  the  ear  well  formed,  the  walls  of  the  body  are 
thicker  and  lose  their  transparency.  The  sex  can  be  distinguished  by 
the  absence  or  presence  of  the  uterus  and  vagina ;  the  umbilical  cord, 
inserted  a  little  above  the  pubes,  reaches  a  length  of  2.7  inches,  seven 
centimetres,  and  begins  to  take  a  spiral  form.  In  the  twelfth  week 
the  ovum  is  the  size  of  a  goose's  egg,  the  embryo  is  from  2.7  to  3.5 
inches,  seven  to  nine  centimetres  long,  and  weighs  five  drachms,  twenty 
grammes. 

At  about  three  months  points  of  ossification  are  found  in  all  parts  of 
the  vertebral  column.  Ossific  formation  begins  in  the  cervical"  vertebrae, 
then  in  the  dorsal,  finally  in  the  lumbar,  and  in  all  the  vertebrae  it 
begins  in  the  bodies  before  it  does  in  the  arches.  Hence,  spina  bifida, 
which  is  a  hernia  of  the  spinal  membranes  through  a  cleft  in  their  bony 
canal,  is  rarely  anterior,  and  it  is  much  more  frequently  lumbar  than 
dorsal  or  cervical. 

FOURTH  MONTH.  The  fetus  is  between  six  and  seven  inches,  seven- 
teen centimetres,  long,  and  weighs  nearly  four  ounces,  three  ounces  and 
three-quarters,  one  hundred  and  twenty  grammes;  the  umbilicus  is 
above  the  lowest  fourth  of  the  linea  alba,  and  the  cord  is  seven  and 
one-half  inches,  nineteen  centimetres,  long.  The  development  of  the 
female  external  sexual  organs  has  been  given  on  page  80 ;  that  of  the 
male  is  the  same  up  to  a  certain  stage,  but  in  the  first  half  of  the  fourth 
month,  in  the  male,  the  genital  fissure  closes,  and  the  genital  folds  are 
united  together  to  form  the  scrotum  ;  the  genital  tubercle,  which  in  the 
female  forms  the  clitoris,  becomes  in  the  male  the  penis,  and  in  the  third 
month  shows  the  formation  of  the  glans.  A  very  distinct  raphe  upon 
the  penis  and  scrotum  indicates  the  place  of  union  of  the  two  sides  of 
the  genital  fissure.  The  prepuce  is  formed  in  the  sixth  month.  The 
prostate,  beginning  in  the  third  month  as  a  thickening  at  the  point 
where  the  urethra  and  genital  cord  meet,  can  be  plainly  seen  in  the 
fourth  month.  If  the  sides  of  the  genital  fissure  fail  to  unite,  the  con- 
dition is  known  as  hypospadias. 

A  slight  down-like  growth  of  hair,  lanugo,  appears  on  the  body,  and 
a  few  hairs  upon  the  head ;  meconium  is  found  in  the  intestine,  and 
feeble  movements  of  the  limbs  occur.  A  foetus  born  at  four  months 
may  live  some  hours ;  no  respiratory  movement  is  made,  but  the  pulsa- 
tion of  the  heart  and  that  of  the  umbilical  cord  are  present ;  Cazeaux 
observed  an  instance  in  which  life  continued  four  hours. 

FIFTH  MONTH.  At  five  months  the  foetus  is  about  ten  inches,  25 
to  27  centimetres,  long,  and  weighs  eight  to  nine  ounces ;  the  average 
is  273  grammes ;  the  umbilical  cord  is  about  twelve  inches,  or  31  cen- 
timetres long.  Hair  on  the  head  and  lanugo  distinct ;  vernix  caseosa 
present.  During  the  month,  usually  about  its  middle,  the  mother,  in 
most  cases,  first  becomes  conscious  of  foetal  movements,  and  the  sounds 
of  the  fcetal  heart  can  be  heard  by  auscultation ;  movements  of  the 
foetus  are  felt  somewhat  earlier  by  the  multigravida  than  by  the  primi- 
gravida.  If  the  foetus  be  born  at  five  mouths,  it  breathes,  cries  faintly, 
and  lives  longer  than  when  born  at  four  months,  but  dies  in  a  few  hours. 

SIXTH  MONTH.  The  foetus  is  12J  inches,  31  centimetres,  in  length, 
and  weighs  a  little  more  than  one  pound,  634  grammes.  Its  form  has 


THE  EMBRYO  AND  FOETUS.  143 

become  rounded  by  the  increase  of  fat,  lauugo  covers  the  body  aud  the 
members  also,  except  the  palms  of  the  hands  and  the  soles  of  the  feet ; 
the  growth  of  hair  upon  the  head  is  plain,  and  the  eyebrows  can  be 
faintly  seen,  while  the  secretion  from  the  sebaceous  glands  furnishes  a 
more  abundant  vernix  caseosa.  A  foetus  born  at  the  end  of  six  months 
may  live  from  one  to  fifteen  days.  Its  death  occurs  not  only  because 
the  digestive  apparatus  is  incompletely  developed,  and  because  the  re- 
duction of  temperature  is  great  and  rapid,  but  because  the  rudimentary 
condition  of  the  lungs  renders  respiration  almost  impossible,1  for,  accord- 
ing to  Cornil,  at  this  period  of  intra-uterine  life  air  cannot  distend  the 
final  pulmonary  ramifications  because  of  their  anatomical  structure. 

SEVENTH  MONTH.  At  the  end  of  the  month  the  foetus  is  13-15 
inches,  33—36  centimetres,  long,  and  weighs  between  3  and  4  pounds, 
1200  grammes.  The  eyelids  are  open,  the  testicles  begin  to  descend  in 
the  seventh  month,  and  are  near  the  scrotum.  The  nails  are  almost 
completely  formed,  the  insertion  of  the  cord  is  about  one  inch  and  a 
half,  four  centimetres,  below  the  middle  of  the  length  of  the  body.  The 
child  is  said  to  be  viable  at  the  end  of  the  month,  but  its  viability  is 
only  relative  to  that  of  earlier  birth ;  the  majority  of  children  born  at 
this  period  die. 

On  the  other  hand,  there  are  instances  in  which  children  born  before 
the  end  of  seven  months  have  lived.  Tarnier  states  that  by  means  of 
the  couveuse  and  gavage  several  accoucheurs  have  succeeded  in  recent 
years  in  saving  infants  whose  intra-uterine  life  was  only  six  months, 
or  six  months  and  some  days. 

A  popular,2  founded  upon  a  professional,  belief  prevailed  for  many  centuries, 
to  the  effect  that  a  child  born  at  seven  months  was  more  likely  to  live  than  one 
born  at  eight  months.  Possibly  this  belief  is  not  yet  quite  extinct.  It  is,  however, 
somewhat  astonishing  to  find  the  late  Dr.  John  W.  Francis,  Professor  of  Obstet- 
rics in  the  University  of  New  York,  in  his  preface  to  the  American  edition  of 
"Denman"  (1821),  using  the  following  language:  "The  singular  circumstance 
that  a  child  of  seven  months'  gestation  has  greater  chance  of  living  than  one  of 
eight  was  noticed  by  him,"  i.  e.,  Hippocrates.  Now,  this  notion,  which  was  held 
for  more  than  two  thousand  years,  had  its  origin  in  the  infancy  of  obstetric 
science,  and  arose  from  ignorance  of  the  essential  cause  of  labor.  It  was  believed 
that  the  foetus  up  to  seven  months  had  its  head  in  the  upper  part  of  the  womb, 
but  at  that  time  the  increased  weight  of  the  head  caused  it  to  fall  into  the  lower 
part  of  the  uterine  cavity ;  the  head  of  a  boy,  from  its  having  greater  size,  turn- 
ing downward  somewhat  earlier  than  that  of  a  girl.  But  as  soon  as  the  foetus 
had  its  head  at  the  mouth  of  the  womb  it  made  an  effort  to  get  out,  and,  if  a 
very  strong  child,  succeeded.  If  it  failed,  the  effort  was  repeated  at  eight  months, 
and  in  case  it  then  succeeded  the  foetus,  haying  been  weakened  by  its  previous 
unsuccessful  attempt,  had  less  chance  of  living  than  if  birth  had  taken  place  at 
seven  months. 

EIGHTH  MONTH.  At  the  end  of  the  eighth  month  the  length  of  the 
foetus  is  about  16  inches,  a  little  more  than  40  centimetres,  and  its 
weight  is  about  5  pounds,  or  nearly  2  kilogrammes.  The  insertion  of 
the  cord  is  about  the  middle  of  the  length  of  the  body ;  only  one  of  the 

1  Pinard. 

2  As  illustrative  of  this  belief  the  following  passage  from  the  Memoirs  of  Madame  Guyon  is 
quoted.    She  was  born  in  1642,  and  was  the  founder  of  that  peculiar  form  of  religious  belief  and 
conduct  known  as  Quietism:    "I  was  born  before  due  time,  for  my  mother,  having  received  a 
terrible  fright,  was  delivered  of  me  at  the  eighth  month,  at  which  time  they  say  it  is  almost  impos- 
sible for  a  baby  to  live." 


144  PHYSIOLOGY  OF  PREGNANCY. 

testicles,  usually  the  left,  is  in  the  scrotum  ;  during  the  month  the  body 
increases  less  in  length  than  in  breadth. 

NINTH  MONTH.  The  length  of  the  foetus  at  term  varies  from  about 
19£  inches  to  a  little  more  than  22  inches,  50-56  centimetres ;  its  weight 
by  many  is  placed  as  between  six  and  seven  pounds  :  Landois,  however, 
makes  it  seven  pounds,  8^  kilos.  The  last  statement  corresponds  more 
nearly  with  that  resulting  from  statistics,  including  500  male  and  500 
female  children,  taken  from  the  obstetric  records  of  the  Philadelphia 
Hospital.1  These  statistics  showed  the  average  weight  of  female  chil- 
dren to  be  seven  pounds  one  ounce  and  a  half,  and  that  of  male  children 
to  be  seven  pounds  eight  ounces.  In  only  one  of  a  thousand  was  the 
weight  eleven  pounds. 

Burns  regarded  the  weight-proportion  between  the  sexes  in  the  new- 
born to  be  such  that  twelve  males  would  weigh  as  much  as  thirteen 
females.  The  late  Sir  James  Simpson  has  drawn  attention  to  the  fact 
that  from  the  great  size  of  the  head  of  the  male  the  foetal  mortality  in 
childbirth  was  larger  with  male  than  with  female  children  ;  Bertillon's 
statistics  prove  that  the  foetal  mortality  in  birth  is  in  the  proportion  of 
130  males  to  100  females.  If  a  child's  weight  at  birth  be  decidedly 
under  the  average,2  the  probability  is  that  the  labor  is  premature,  or  else 
the  normal  development  of  the  child  has  been  interfered  with.  So,  too, 
if  the  weight  be  much  above  the  average,  it  is  possible  that  in  some 
cases  the  pregnancy  has  been  protracted  beyond  the  normal  time. 

In  one  instance  in  my  practice  a  child  was  born  weighing  only  one  pound  and 
a  half,  the  pregnancy  ending  a  few  days  before  the  completion  of  the  seventh 
month ;  the  child  lived,  and  is  now  a  healthy  boy  of  ten  years.3 

Dr.  R.  P.  Harris,  in  a  note  to  "  Playfair,"  states  :  "  We  have  had  children  born 
in  this  city,  Philadelphia,  at  maturity  that  weighed  but  one  pound.  The  well- 
remembered  '  Pincus '  baby  weighed  a  pound  and  an  ounce." 

In  some  instances  children  weighing  twelve  pounds  and  even  more  have  been 
born.  But  it  is  remarkable  that  most  of  the  cases  of  birth  of  unusually  large 
children  occur  in  private,  not  in  hospital  practice.  Pinard,  from  an  examination 
of  the  records  of  the  Paris  University,  found  but  one  in  20,000  that  weighed 
5300  grammes,  a  little  more  than  twelve  pounds. 

Nevertheless  children  have  been  born  whose  weight  was  very  much  greater 
than  even  this.  For  example,  Dr.  Adye,  of  Bentonville,  Ind.,  in  a  recent  letter 
to  me  states  that  in  his  practice  a  woman  was  delivered  spontaneously  and 
rapidly  of  a  child  weighing  16  pounds  ;  both  mother  and  child  did  well.  The 
most  extraordinary  case  that  has  been  communicated  to  me,  however,  was  one 
occurring  in  the  practice  of  Dr.  Josiah  Peltz,  of  this  city.  On  the  29th  of 

1  I  am  indebted  to  Dr.  R.  J.  Phillips,  one  of  the  internes  at  the  time,  for  preparing  these  statistics. 
A  curious  fact  which  I  have  observed  in  my  hospital  service  is,  that  there  is  less  difference  in 
weight  between  the  sexes  of  the  newborn  in  the  black  than  in  the  white.    While  a  sufficient 
number  of  observations  have  not  been  made  to  establish  a  law,  there  are  a  priori  reasons  for 
believing  in  its  possibility. 

2  Kormann,  op.  cit.,  believes  that  pregnancy  may  last  at  least  two  or  three  weeks  beyond  two 
hundred  and  eighty  days,  and  that  then  the  foetus  may  be  developed  beyond  the  average,  so 
that  its  weight  is  6000  grammes,  and  its  length  30  centimetres.    This  subject  will  be  referred  to 
again  in  connection  with  the  topic  of  prolonfred  pregnancy. 

a  Gilbert  (Zeitschrift  fur  Geburtshiilfe  und  Gynakologie,  Band  16,  Heft  1)  reports  the  case  of  a 
female  child,  born  in  the  twenty-ninth  week  of  gestation,  weighing  three  and  a  half  pounds ;  the 
child  was  twenty-two  inches  long  when  five  and  a  half  months  old.  Various  incubators  were 
tried,  but  daily  warm  baths  were  most  successful.  The  child  was  taken  into  the  open  air  from  the 
moment  of  birth.  For  the  first  week  a  wet-nurse  fed  the  infant ;  afterward  the  mother.  From  the 
seventeenth  day  it  was  fed  breast-milk  with  a  spoon.  When  eighteen  weeks  old  cow's  milk  was 
given. 

In  growth  the  greatest  gain  occurred  at  the  time  when  birth  would  have  normally  occurred. 
The  child  suffered  from  frequent  attacks  of  syncope  until  its  fourth  year  ;  it  had  also  spinal  curva- 
ture (scoliosis  35°)  from  rhachitis;  this  was  afterward  reduced  by  orthopedic  treatment  (to  5°). 
The  milk  teeth  were  complete  at  three  and  a  half  years. 


PLATE    II 


THE  MATURE  OVUM.     (After  Runge. ) 

A.  Uterine  wall. 

B.  Placenta. 

C.  Umbilical  cord. 

D.  Decidua. 

E.  Chorion. 

F.  Amnion. 

G.  Fcetus. 

H.  Amnial  liquor. 


[To  face  page  145. 


THE  EMBRYO  AND  FCETUS. 


145 


October,  1887,  he  delivered  Mrs.  S.,  at  the  end  of  her  fourth  pregnancy,  of  a 
female  child  weighing  22  pounds.  The  child  was  stillborn,  but  the  doctor 
believes  that  it  could  have  been  resuscitated  had  proper  means  been  used  ;  the 
means  were  not  used  because  for  some  time  his  sole  care  was  of  the  mother, 
who  had  dangerous  uterine  hemorrhage.  Dr.  Peltz  states  that  his  patient  is  a 
woman  of  unusual  size,  ordinarily  weighing  225  pounds,  and  that  her  pelvis  is 
remarkably  large. 

My  friend  Dr.  T.  G.  Davis,  of  Bridgeton,  N.  J.,  informs  me  that  Dr.  J.  R. 
Thompson,  of  that  city,  delivered,  with  forceps,  a  woman  of  a  dead  child  which 
weighed  21  pounds. 

Harris,  op.  cit.,  says  :  "  Probably  the  largest  foetus  on  record  was  that  of  Mrs. 
Captain  Bates,  the  Novia  Scotia  giantess,  a  woman  of  7  feet  9  inches  in  height, 
whose  husband  is  also  of  gigantic  build,  reaching?  feet  7  inches  in  height.  This 
child,  born  in  Ohio,  was  their  second,  and  was  lost  in  its  birth,  as  no  forceps  of 
sufficient  size  to  grasp  the  head  could  be  procured.  The  fo3tus  weighed  twenty- 
eight  and  three-fourths  pounds,  and  was  thirty-nine  inches  in  length.  Their  first 
infant  weighed  nineteen  pounds." 

Considering  the  pregnancy  as  lasting  ten  lunar  months,  the  following 
is  the  length  of  the  embryo  or  foetus  at  the  end  of  each  month,  as  stated 
by  Haase  : 


At  the  end  of  the  first  month 

second  month 

third 

fourth 

fifth 

sixth 

seventh 

eighth 

ninth 

tenth 


1X1=1  cm.  or   0.395  inch. 
2X2=4  cm.  or   1.58   inches. 
3X3=9  cm.  or    3.55 

4  X  4  =  16  cm.  or  6.23 

5  x  5  =  25  cm.  or  9.87 

6  x  5  =  30  cm.  or  11.85 

7  X  5  =  35  cm.  or  13.82 

8  x  5  =  40  cm.  or  15.80 

9  x  5  =  45  cm.  or  17.77 
10  X  5  =  50  cm.  or  19.75 


THE  FCETUS  AT  TERM.  There  is  no  single  criterion  by  which  the 
maturity  of  the  foetus  can  be  known,  but  a  strong  probability,  amounting 
to  almost  absolute  certainty,  is  attained  by  combining  certain  charac- 
teristics. Thus  the  foetus  should  have  the  average  weight  and  length 
that  have  been  given  ;  the  body  should  be  plump,  and  more  or  less 
covered  with  the  secretion  from  the  sebaceous  glands,  this  secretion 
being  mixed  with  the  detached  lanugo  and  epithelial  scales  making  the 
vernix  caseosa,  or  cheesy  varnish  ;  this  covering  is  chiefly  in  the  groins 
and  axillae,  at  the  flexures  of  the  joints,  and  upon  the  back  and  chest. 
The  nails  of  the  fingers  and  toes  are  hard,  those  of  the  former  projecting 
slightly  beyond  the  tips  of  the  fingers  ;  the  cartilages  of  the  ear  and 
nose  are  resisting  ;  the  cord  is  usually  a  little  below  the  middle  of  the 
anterior  portion  of  the  body,  in  girls  the  insertion  is  said  to  be  a  little 
higher  than  in  boys  ;  the  hair  on  the  head  is  one  to  two  inches,  2.6  to 
5.2  centimetres,  long  ;  the  child  cries  vigorously,  and  makes  active 
efforts  at  sucking  an  object  placed  between  its  lips.  (See  Plate  II.) 

THE  FCETAL  HEAD.  This  is  the  part  of  the  foetus  which  is  usually 
expelled  first,  and  if  it  can  pass  through  the  birth-canal  there  is  rarely 
difficulty  or  delay  in  the  delivery  of  the  body,  and  hence  the  knowledge 
of  its  form,  size,  and  structure,  and  the  changes  in  its  measurements 
and  shape  occurring  in  labor,  is  important  for  the  obstetrician.  The 
general  shape  of  the  foetal  head  is  ovoidal,  the  larger  end  of  the  ovoid 
being  posterior.  It  is  composed  of  cranium  and  face  ;  the  latter  is  of 
minor  obstetric  importance.  The  bones  of  the  cranium  of  the  foetus 
differ  from  those  of  the  adult's  cranium  in  two  important  respects  : 
they  are  to  some  degree  flexible  in  consequence  of  incomplete  ossifica- 

10 


146 


PHYSIOLOGY  OF  PREGNANCY. 


tion,  and  they  are  mobile,  because  instead  of  being  united  together  by 
bone,  their  union  is  by  fibrous  tissue.  Further,  in  the  foetal  head 
mobility  of  the  squamous  portion  of  the  occipital  results,  as  pointed  out 
by  Budin,1  from  its  being  united  to  the  basilar  portion  by  cartilage, 
which  serves  as  a  hinge,  and  the  former  is  moved  forward  or  backward 
according  to  the  action  of  external  force. 

SUTURES  AND  FOJNTANELLES.  The  membranous  spaces  between  the 
bones  of  the  head  are  called  sutures  and  fontanelles.  The  sutures  are 
straight  or  curved  lines,  and  the  fontanelles  are  at  the  junction  or  at 
the  intersection  of  sutures ;  if  at  the  former,  the  fontanelle  is  triangular, 
but  if  at  the  latter,  quadrangular.  The  three  most  important  sutures 
are  the  sagittal,  the  fronto-parietal,  and  the  occipito-parietal.  The 
sagittal — from  sagitta  an  arrow,  meeting  the  bowstring  at  a  right 
angle,  passing  directly  over  the  bend  of  the  bow,  and  thus  intersecting 
the  middle  of  the  arc  described  by  the  fronto-parietal  suture — is  the 
longest,  and  extends  from  the  root  of  the  nose  to  the  upper  point  or 

FIG.  89. 


ANTERIOR  AND  POSTERIOR  FONTANELLES,  SAGITTAL  AND  OCCIPITO-PARIETAL  AND 
OCCIPITO-FRONTAL  SUTURES. 

angle  of  the  occipital  bone ;  it  is  the  dividing-line  between  the  two 
halves  of  the  frontal  bone  and  between  the  two  parietal  bones.  The 
fronto-parietal,  as  its  name  indicates,  is  between  the  frontal  and  the 
parietal  bones ;  it  ends  on  either  side  at  the  squamous  portion  of  the 
temporal  bone.  The  occipito-parietal,  usually  called  lambdoidal  from 
its  suggested  resemblance  to  the  Greek*  letter  lambda,  a,  is  between  the 
occipital  and  parietal  bones  ;  it  may  be  described  as  a  bifurcation  of  the 
sagittal  suture. 

The  chief  fontanelles  are  two,  one  anterior,  the  other  posterior.  The 
former,  also  called  bregma,  from  8p£%u  to  moisten,  because  of  its  being 
so  yielding  to  the  touch,  is  at  the  intersection  of  the  two  sutures,  the 
sagittal  and  the  fronto-parietal,  and  therefore  quadrangular.  It  is  a 
large,  membranous  depressed  surface,  with  unequal  sides,  the  two  ante- 


1  De  la  Tete  du  Foetus  au  point  de  vue  de  1'Obstetrique. 

2  Its  resemblance  is  greater,  as  Bailly  has  said,  to  a  capital  V,  whose  angle  corresponds  to  the 
end  of  the  sagittal  suture. 


THE  EMBRYO  AND  FCETUS.  147 

rior  being  longer  than  the  two  posterior ;  these  features  are  so  charac- 
teristic that  its  recognition  in  labor  by  the  touch  ing- finger  is  usually 
quite  easy.  The  posterior  foutauelle  is  at  the  junction  of  the  sagittal 
with  the  occipito-parietal  suture,  it  is  consequently  triangular ;  it  is 
quite  small,  and  in  labor  cannot,  as  a  rule,  be  recognized  as  a  mem- 
branous space,  for  in  consequence  of  the  movement  of  the  squamous 
portion  of  the  occipital  bone  forward,  the  overriding  parietal  bones  hide 
it  from  touch  ;  but  its  position  may  be  recognized  by  its  corresponding 
with  the  point  of  apparent  bifurcation 
of  the  sagittal  suture,  and  by  its  being  FIG.  90. 

at  the  apex  of  a  depressed  triangle, 
two  of  the  converging  sides  of  the 
triangle  being  the  posterior  margin  of 
each  parietal  bone,  and  the  inter- 
vening space  occupied  by  the  occipital 
bone. 

Lateral  and  supplementary  fonta- 
nelles  are  also  to  be  noticed.  The 
chief  of  the  former  are  at  the  junction 
of  the  occipito-parietal  and  temporal 
sutures,  but  they  are  concealed  by  soft 
parts.  Supplementary  fontanelles  are 

membranous  spaces  arising;  from  fail- 

„         .         V  &  .  ANTERO-POSTERIOE  DIAMETERS  OF  FCETAL 

ure  ot  ossification ;  they  are  sometimes  HEAD. 

found  in  the  middle  of  a  bone,  some- 
times in  the  course  of  a  suture;  remembering  these  facts  as  to  their 
position,  one  is  not  liable  to  confound  them  with  either  of  the  fonta- 
nelles that  have  been  described,  and  which  are  such  important  guides 
in  practical  obstetrics. 

DIAMETERS  OF  THE  FCETAL  HEAD.  These  are  lines  drawn  between 
certain  points  of  the  foatal  head.  Following  the  example  of  Budin, 
these  diameters  may  be  classified  according  to  their  general  direction, 
as  antero-posterior,  transverse,  and  vertical.  The  antero-posterior  are 
four,  viz.,  the  maximum,  the  occipito-mental,  the  occipito-frontal,  and 
the  suboccipito-bregmatic. 

The  maximum  diameter  extends  from  the  chin  to  a  variable  point, 
which  is  in  almost  every  case  situated  in  the  sagittal  suture  between  the 
two  fontanelles.  The  occipito-mental  diameter  reaches  from  the  point 
or  angle  of  the  occiput  to  the  chin.  The  occipito-frontal  is  between  the 
angle  of  the  occiput  and  the  r.oot  of  the  nose,  and  the  suboccipito-breg- 
matic is  from  the  point  of  meeting  of  the  occipital  bone  with  the  nucha 
to  the  middle  of  the  anterior  fontanelle,  that  is,  where  the  sagittal  and 
fronto-parietal  sutures  cross  each  other. 

The  transverse  diameters  are  three,  viz.,  the  biparietal,  between  the 
parietal  protuberances,  the  bitemporal,  between  the  origin  of  the  fronto- 
parietal  suture  on  each  side,  and  the  bimastoid,  which  extends  between 
the  mastoid  apophyses. 

The  vertical  diameters  are  two,  the  fronto-mental,  extending  between 
the  highest  point  of  the  forehead  and  the  chin,  and  the  trachelo-breg- 
matic,  from  the  middle  of  the  anterior  fontanelle  to  the  -upper  and 


148 


PHYSIOLOGY  OF  PREGNANCY. 


anterior  part  of  the  neck  in  the  immediate  vicinity  of  the  larynx.    This 
diameter  is  also  called  the  cervico-bregmatic  and  the  laryngo-bregmatic. 


FIG.  91. 


FIG.  92. 


BlPARIETAL  AND  BlTEMPORAL  DIAMETERS 
OF  FCETAL  HEAD. 


VERTICAL  DIAMETERS. 


The  illustration  which  follows,  taken  from  Tarnier,  shows  the  three 
diameters,  suboccipito-bregmatic,  suboccipito-frontal,  and  suboccipito- 
nasal,  as  measured  in  an  infant  immediately  after  delivery.  The  fact 
of  the  second  diameter  being  greater  than  either  of  the  others,  and 
hence  the  circumference  of  the  child's  head  corresponding  with  it  will 
be  that|which  will  be  with  the  greatest  difficulty  forced  through  the 


THE  THREE  SUBOCCTPITAL  DIAMETERS. 


vulval  ring,  are  apparent.  The  importance  of  this  diameter  in  regard 
to  expulsion  of  the  head,  that  is,  the  greater  danger  to  the  perineum  at 
the  time  its  circumference  passes,  has  been  in  recent  years  especially 


THE  EMBRYO  AND  F(ETUS. 


149 


urged  by  Matthews  Duncan  and  by  Ribemont.  But  long  before  them 
Smellie  and  Burton  had  referred  to  the  essential  fact. 

The  greatest  circumference  of  the  foetal  head  is  that  corresponding 
with  the  maximum  diameter,  and  the  least  that  which  is  similarly  re- 
lated to  the  suboccipito-bregmatic. 

In  the  following  table  of  diameters  and  circumferences  the  measure- 
ments given  by  Tarnier  and  Chantreuil  are  presented.  Each  metric 
measurement  is  followed  by  its  equivalent  in  inches  and  hundredths, 
and  this  in  turn  by  an  approximative  measurement,  where  it  seemed 
most  convenient  for  remembering,  substituting  vulgar  for  decimal 
fractious. 


Maximum  diameter 

Occipitomental 

Occipito-frontal 

Suboccipito-bregmatic 

Biparietal 

Bimastoid 

Fronto-mental 

Bitemporal 

Trachelo-bregmatic 

Great  circumference 

Small  circumference 


.    13.5  cn 

.     13.      " 

.     12. 

.      9.5 

.      9.5 

.      7.5 

.      8. 

.      8. 
.      9.5 

.    37. 

.     32.5 

5.31  inches  or  5X 


5.11 
4.72 
3.75 
3.75 
2.75 
3.15 
3.15 
3.75 
14.57 
12.80 


if 
i 

8 


14^ 
12% 


Upon  comparing  these  diameters  of  the  foetal  head  with  those  of  the 
maternal  pelvis,  it  will  be  seen  that  only  two  of  the  former  exceed  the 
greatest  of  the  latter ;  but  in  normal  labor  neither  of  the  two  is  brought 
in  relation  with  a  pelvic  diameter. 

MODIFICATION  OF  DIAMETERS  OF  FCETAL  HEAD  IN  LABOR.  Budin 
has  shown  that  certain  modifications  in  the  diameters  of  the  fostal  head 
are  produced  by  the  overriding  of  bones  at  the  sutures,  from  the  pres- 
sure upon  the  head  in  passing  through  the  pelvis,  and  that  by  these 
changes  the  head  is  changed  in  shape,  the  change  varying  with  the 
position.  In  general  the  alterations  in  the  diameters  are  as  follows : 
the  occipito- mental  and  occipito-frontal  diameters  are  lessened  ;  the 
maximum  diameter  is  increased ;  the  suboccipito-bregmatic  and  the 
bitemporal  are  lessened ;  the  biparietal  is  very  slightly  lessened ;  but 
the  mastoid  not  changed. 

MOVEMENTS  OF  THE  FCETAL  HEAD.  The  head  may  be  bent  for- 
ward or  backward  so  as  to  come  in  contact  with  the  body ;  the  first  is 
called  complete  flexion,  and  the  second  complete  extension  ;  this  move- 
ment takes  place  chiefly  in  the  articulations  of  the  cervical  vertebrae, 
the  occipito-atlantoid  articulation  participating  only  very  slightly.  The 
last  articulation,  however,  permits  rotation  of  the  head  to  the  right  or 
to  the  left  through  a  quarter  of  a  circle.  Tarnier,  in  reply  to  the  ques- 
tion whether  the  head  can  be  made  to  rotate  much  more  extensively 
without  injury  to  the  cord  or  to  the  ligaments,  asserts  that  the  fears  ex- 
pressed are  purely  theoretical,  and  that  a  movement  of  rotation  so 
extensive  that  the  face  is  turned  directly  backward  may  be  made  without 
producing  any  lesion.  This  topic  will  be  again  referred  to. 

DIAMETERS  OF  THE  TRUNK.  The  bis-acromial  diameter  from  one 
acromion  to  the  other  is  the  longest  trunk  diameter.  It  is  4.7  inches,  or 
12  centimetres ;  it  can  be  reduced  one  inch,  or  to  9.5  centimetres.  The 
dorso-sternal  is  3.7  inches,  9.5  centimetres.  The  bis-trochanteric  diam- 
eter is  3.5  inches,  9  centimetres.  The  sacro-pubic  diameter  is  a  little 
more  than  2  inches,  5.5  centimetres ;  by  the  flexion  of  the  thighs  upon 


150 


PHYSIOLOGY  OF  PREGNANCY. 


FIG.  94. 


the  abdomen  and  the  legs  upon  the  thighs  this  diameter  is  nearly 
doubled,  but  compression  readily  lessens  it.  All  the  trunk  diameters 
lessen  by  compression  more  than  do  those  of  the  head. 

INCREASE  IN  WEIGHT  AND  LENGTH  OF  FCETUS  IN  SUCCESSIVE  PREGNANCIES. 
As  a  matter  that  is  of  great  practical  importance  in  some  cases  in  reference  to 
obstetric  treatment,  it  may  be  stated  that  from  the  weight  and  length  of  the  child 
of  the  immediately  previous  birth  those  of  the  next  can  be  determined.  The 
increase  in  weight  is,  on  the  average,  150  grammes,  and  in  length  0.75  centimetre. 
Suppose  that  in  the  first  labor  the  child  has  the  average  weight  and  length,  the 
following  table  shows  approximately  those  of  children  born  subsequently ;  it  has 
been  taken  from  Ahlfeld : 

The  second  child's  weight  will  be  3400  gr.,  its  length  51.75  cm. 
The  third         "  "  "     3550  gr.,        "  52.50    " 

The  fourth       "  "     3600  gr.,        "  53.25    " 

The  fifth  "  "     3750  gr.,        "  54.50    " 

ATTITUDE  OF  THE  FCETUS  IN  THE  WOMB.  By  this  are  meant  the 
general  form  and  direction  of  the  truuk,  and  the  position  of  the  limbs 

with  reference  to  it.  We  have  seen  that 
in  the  very  dawn  of  development  the  first 
distinct  form  which  the  embryo  had  was 
that  of  a  curve,  the  ends  of  that  curve 
tending  to  approach  ;  and  the  curved 
form  is  kept  through  all  intra-uterine 
life.  As  shown  in  the  above  diagram  of 
the  foetus  contained  in  the  uterine  cavity, 
the  back  is  bent  forward,  the  chin  in- 
clined to  the  chest,  the  arms  folded  over 
the  breast,  the  feet  flexed,  the  legs  flexed 
upon  the  thighs,  and  the  thighs  upon  the 
abdomen ;  the  foetus  is  thus  folded  upon 
itself,  making  an  ovoid,  its  position  being 
not  unlike  that  of  a  chrysalis  in  the 
cocoon,  or  a  chick  in  the  shell.  Harvey's 
explanation  of  the  attitude  of  the  foetus 
was  this:  "The  truth  is,  that  all  animals, 
whilst  they  are  at  rest  or  asleep,  fold  up 
their  limbs  in  such  a  way  as  to  form  an 
oval  or  globular  figure ;  so  in  like  man- 
ner embryos,  passing  as  they  do  the 

greater  part  of  their  time  in  sleep,  dispose  their  limbs  in  the  position  in 
which  they  are  found,  as  being  most  natural  and  best  adapted  for  their 
state  of  rest."  ^  Cazeaux  regarded  the  attitude  of  the  foetus  as  represent- 
ing "a  constrained  position,  which  could  not  have  been  produced  by  the 
mere  pressure  of  the  uterine  walls  upon  the  child,  since  the  latter  is  in 
a  cavity  much  larger  than  its  whole  volume ;  hence  it  must  be  referred 
to  the  individual  itself." 

^  As  has  already  been  stated,  the  attitude  of  the  foetus  is  the  perpetua- 
tion of  that  of  the  embryo,  and  the  primitive  form  of  the  latter  must 
be  regarded  as  one  of  the  factors  in  causing  it.  But  others  are  also 
concerned — indeed,  by  some  made  the  exclusive  factors ;  Pinard,  for 


POSTURE  OP  THE  FCETOS. 


THE  EMBRYO  AND  FCETUS.  151 

example,  saying1  that  the  causes  are  material,  extrinsic,  and  belong  to 
the  pressure-forces  much  more  than  to  the  individual — and  these  will 
be  considered  under  the  next  topic. 

PRESENTATION  OF  THE  FCETUS.  By  presentation  is  meant  that  part 
of  the  foetus  which  is  in  relation  with  the  pelvic  inlet,  and  in  labor  first 
descends  into  the  pelvic  cavity  ;  that  part,  in  a  word,  which  presents  at 
the  inlet  and  in  the  cavity.  In  about  ninety-six  per  cent,  of  cases  of 
labor  at  term  the  head  presents;  many  obstetric  authorities  indeed 
regard  this  as  the  only  normal  presentation,  as  it  is  certainly  the  most 
favorable.  Various  explanations  have  been  given  of  the  fact. 

The  Hippocratic  theory  held  that  the  foetus  was  attached  by  liga- 
ments passing  from  the  umbilicus  to  the  fundus  of  the  womb,  its  head 
being  above ;  rupture  of  the  ligaments  occurred  at  seven  months,  and 
then  the  child  immediately  turned  its  head  down  and  attempted  to 
force  its  way  out  of  the  womb.  Aristotle  held  with  Hippocrates  as  to 
the  original  position  of  the  child,  but  added  gravity  in  explaining  the 
turning  downward  of  the  head.  Trentius,  1564,  found  in  the  form  of 
the  uterus  the  reason  for  the  head  usually  being  in  its  lower  portion  at 
labor.  The  illustrious  Pare"  attributed  the  presentation  to  instinct. 
Dubois  sustained  this  hypothesis,  illustrating  it  by  instinctive  acts  of 
the  newborn  seeking  the  nipple  and  sucking.  Sir  James  Simpson  held 
that  reflex  action  was  not  the  exclusive  but  the  ancillary  cause,  using 
the  following  language  :2  "  At  and  toward  the  full  term  of  utero-gesta- 
tion  the  position  of  the  foetus  with  its  head  lowest  is  thus  greatly  main- 
tained by  the  relative  physical  adaptation  of  the  ovoid  shape  of  the 
rolled-up  mass  of  the  foetus  to  the  ovoid  shape  of  the  cavity  of  the 
uterus.  But  this  particular  adaptation  and  position  of  the  foetus 
would  be  often  lost  if  no  other  additional  and  vital  means  were  in 
operation,  as  we  see,  indeed,  often  happens  when  the  child  dies.  The 
other  additional  means,  by  whose  influence  this  special  position  is  still 
further  rigorously  and  carefully  sustained,  consists  of  the  restoring 
influence  of  reflex  motions  on  the  part  of  the  foetus  itself." 

The  gravitation  theory  proposed  originally,  as  we  have  seen,  by 
Aristotle,  is  advocated  by  some  to-day  as  an  assisting,  by  others  as  the 
chief  cause,  notwithstanding  the  experiments  of  Dubois  and  the  criti- 
cisms of  Simpson,  which  appear  conclusively  to  disprove  it. 

One  of  the  most  curious  of  modern  hypotheses,  mentioned  by  Cohnstein3  in 
his  paper  upon  "Normal  Presentation  of  the  Foatus,"  is  that  of  Probsting.  The 
head  presents  because  of  the  efforts  of  nature  to  place  the  orifice  of  the  respira- 
tory organs  of  the  foetus  as  near  as  possible  to  atmospheric  air. 

Cohustein  denies  that  the  cause  of  presentation  of  the  head  is  in  the 
movements  of  the  foetus,  or  in  forces  external  to  it,  but  asserts  that  it 
is  in  the  foetal  circulation,  for  until  seven  months  a  larger  amount  is 
sent  to  the  upper  part  of  the  body,  but  then  the  amount  of  blood  is 
equalized. 

For  Pinard  one  law  governs  the  relations  between  the  foetal  and  the 
maternal  organism,  and  this  law  is  absolutely  the  same  as  the  law  of 

1  Dictionnaire  Encyclopedique  des  Sciences  Medicales. 

2  Obstetric  Works. 

3  Archives  Generales  de  Medecine,  1869  and  1870. 


152  PHYSIOLOGY  OF  PREGNANCY. 

accommodation  of  labor  so  well  formulated  by  Professor  Pajot :  Wfien 
a  solid  body  is  contained  in  another,  if  the  container  is  the  seat  of  alter- 
nate movement  and  rest,  if  ihe  surfaces  are  slippery  and  little  angular,  the 
content  constantly  tends  to  accommodate  its  form  and  dimensions  to  the 
form  and  capacity  of  the  container. 

While  this  law  explains  the  presentation  of  the  head  of  the  foetus 
better  than  the  gravitation  theory,  or  that  of  instinctive  or  reflex  fcetal 
movements,  it  seems  probable  that  it  is  not  the  sole  cause  of  the  attitude 
of  the  foetus,  but  merely  assists  the  action  of  the  primitive  cause. 

Studying  Pajot's  law,  as  it  relates  to  presentation  alone,  we  find  in 
the  painless  contractions  of  the  uterus  in  pregnancy,  in  the  varying 
abdominal  pressure,  and  the  changes  of  position  of  the  mother,  which 
have  more  or  less  action  upon  the  foetus,  the  conditions  of  movement 
and  rest ;  the  foetus  presents  more  of  a  rounded  than  of  an  angular 
surface,  and  after  the  secretion  of  the  sebaceous  glands  begins  this 
surface  is  smooth,  slippery,  and  thus,  the  amnial  liquor  assisting,  the 
accommodation  of  the  content  to  the  container  is  effected.  This  accom- 
modation fails  in  those  months  of  pregnancy  when  the  uterus  is  very 
much  larger  than  the  foetus.  Thus  Veit's  statistics  show  that  in  247 
deliveries  between  the  first  of  the  fifth  and  the  sixth  mouth  the  head 
presented  in  140,  the  pelvis  in  95,  and  the  trunk  in  12.  If  the  foetus 
be  dead  and  macerated,  one  of  the  conditions  of  the  law  fails,  the  con- 
tent is  no  longer  a  solid  body,  and  statistics  show  that  in  very  nearly 
one-half  of  the  cases  in  which  delivery  takes  place  before  six  months 
the  pelvis  presents. 

As  pointed  out  by  Sir  James  Simpson,  presentation  of  the  pelvis  is 
common  if  the  child  be  hydrocephalic ;  here  it  is  evident  that  accommo- 
dation causes  the  presentation.  In  twin  pregnancies  accommodation  is 
difficult,  and  Kleinwachter's  statistics  show  presentation  of  the  head  in 
69  per  cent.,  of  the  pelvis  in  25  per  cent.,  and  of  the  shoulder  in  5  per 
cent.  In  polyhydramnios  the  foetus  is  usually  small,  and  thus  ample 
space  doubly  secured  interferes  with  accommodation,  so  that  malpre- 
sentations  are  common. 

Pinard1  attaches  great  importance  to  the  action  of  the  abdominal  wall 
in  assisting  in  accommodation  ;  its  elasticity  and  the  contraction  of  its 
muscles  prevent  the  uterus  from  departing  from  the  median  line — press 
it  at  all  points,  especially  upon  the  sides.  He  attributes  the  greater 
frequency  of  malpresentations  in  multipart,  seven  to  one  in  primiparse, 
to  the  relaxation  of  the  abdominal  muscles  caused  by  preceding  preg- 
nancies. So,  also,  he  assigns  to  the  same  cause  the  frequent  changes  of 
position  of  the  foetus  in  pregnancy  and  the  delay  in  the  engagement  of 
the  presenting  part  in  the  latter  weeks.  Nevertheless,  while  admitting 
the  force  of  these  arguments,  much  must  also  be  ascribed,  as  held  by 
Charpentier,  to  the  greater  relaxation  of  the  multiparous  than  of  the 
primiparous  womb,  and  its  larger  cavity  as  accounting,  in  part  at  least, 
for  these  results. 

Pinard  divides  the  causes  into  active  and  passive.  The  latter  are 
the  forms  of  the  uterus  and  of  the  foetus  in  the  different  periods  of 

i  Op.  cit. 


THE  EMBRYO  AND  FCETUS.  153 

pregnancy,  the  folding  together  of  the  foetal  body  and  limbs,  the  gliding 
surface  of  the  foetus,  and  the  amnial  liquor.  The  active  causes  are  the 
contractions  of  the  uterus,  the  painless  contractions  of  pregnancy,  and 
the  contractions  and  tonicity  of  the  muscles  of  the  abdominal  wall. 

Winckel  concludes  that  the  position  and  attitude  of  the  child  are  determined 
principally  by  the  shape  and  activity  of  the  uterus,  aided  by  the  shape  and  move- 
ments of  the  parts  of  the  foetus,  and  that  the  predominance  of  cephalic  presenta- 
tions results  from  the  direction  of  uterine  force,  the  greater  size  of  the  upper 
than  of  the  lower  segment  of  the  uterus,  the  greater  mobility  of  the  child's  head, 
and  the  shape  of  the  uterus  and  child,  the  latter  being  better  adapted  to  the 
former  when  the  head  presents. 

It  must  be  obvious  that  the  most  important  part  of  this  explanation  is  that 
which  rests  upon  Pajot's  law,  previously  stated. 

Dr.  D.  T.  Smith,  of  Louisville,  Ky.,  some  time  since  J  gave  an  original  explana- 
tion of  the  cause  of  presentation  of  the  head,  and  has  recently  repeated  it  :2 
"  Whoever  has  practised  diving  in  deep  water  has  discovered  that  if  he  holds  his 
arms  in  such  a  way  as  not  to  hinder  his  progress — folded  at  his  back  or  breast, 
for  instance,  or  pressed  to  his  sides — and  then  kicks  out  with  his  feet  he  will  go 
directly  to  the  bottom.  Now  the  position  of  the  child  in  the  uterus,  and  the 
course  of  its  development,  are  such  that  it  makes  essentially  similar  movements. 
The  flaccid  state  of  the  walls  of  the  uterus  allows  them  to  yield  when  pressed 
against  by  the  lower  limbs,  and  in  this  way  the  foatus  gains  the  advantage  that 
would  accrue  to  it  from  swimming  in  a  larger  mass  of  water  than  that  contained 
in  the  uterus.  Adding  to  the  influence  of  these  movements  the  increasing 
conicity  of  the  lower  segment  of  the  uterus  that  develops  during  the  latter  months 
of  pregnancy,  we  can  easily  account  for  the  greater  preponderance  of  head 
presentations.  In  every  position  the  mother  takes,  except  that  of  lying  on  the 
side,  the  outlet  of  the  uterus  is  lower  than  the  fundus,  and  in  all  except  the 
latter  the  movements  the  child  spontaneously  makes  will  tend  to  place  its  head 
downward." 

Dr.  Smith  has  more  recently  presented  his  views  in  a  valuable  monograph 
entitled  Obstetric  Problems,  1892. 

Foulis 3  concludes  from  the  study  of  sections  through  the  pelvis  and  abdomen 
that  the  continual  movements  of  the  child's  lower  limbs  in  extension  cause  the 
head-downward  position.  The  prevalence  of  the  situation  of  the  occiput  and 
back  on  the  mother's  left  side  results  from  the  proportionally  large  size  of  the 
liver  in  the  pregnant  woman,  which  fits  over  the  uterus  like  a  cap,  affording  firm 
resistance  to  the  impact  of  the  child's  feet. 

PHYSIOLOGY  OF  THE  FCETUS.  The  chief  foetal  functions  are  nutri- 
tion, circulation,  respiration,  secretion,  innervation,  and  motility. 

NUTRITION.  It  is  supposed  that  the  nutrition  of  the  impregnated 
ovule  is  at  first  by  the  granular  matter,  the  discus  proligerus,  which 
surrounds  it  when  it  escapes  from  the  ovisac.  In  some  of  the  inferior 
animals  the  ovule,  during  its  passage  through  the  oviduct,  receives  a 
covering  of  albumin,  and  probably  the  same  fact  exists  in  the  human 
ovule;  if  so,  this  albuminous  coat  may  nourish  it.  After  entering  the 
womb  the  primitive  chorial  villi  absorb  nutritive  material  from  the 
uterus  ;  the  granular  contents  of  the  umbilical  vesicle  probably  nourish 
the  embryo,  but  as  the  vesicle  is  atrophied  at  the  end  of  the  fifth  week, 
this  supply  lasts  but  a  short  time. 

The  question  as  to  the  amnial  liquor  contributing  to  the  nourishment 
of  the  foetus — that  it  is  the  sole  or  chief  supply  no  one  now  holds — is 

1  American  Practitioner  and  News,  1887. 

2  American  Journal  of  Obstetrics,  1890. 

3  Edinburgh  Medical  Journal,  September  and  October,  1888. 


154  PHYSIOLOGY  OF  PREGNANCY. 

still  in  dispute.  According  to  Fehling,  the  human  embryo  has  at  the 
sixth  week  97.54  per  cent,  of  water  ;  in  the  fourth  month  the  quantity 
of  water  of  the  fetus  is  between  88  and  93  ;  in  the  fifth,  between  88 
and  93 ;  in  the  sixth,  between  83  and  90 ;  in  the  seventh,  between  82 
and  85  ;  and  in  the  mature  foetus  born  dead,  74.1.  Bischoff,  however, 
found  in  the  newborn  only  66.4  per  cent,  of  water.  Preyer's  statements 
as  to  the  foetus  obtaining  water  from  the  amnial  liquor  by  swallowing, 
and  by  absorption  through  the  skin,  have  been  given  on  page  127. 
Further,  while  the  percentage  of  albumin  in  the  amnial  liquor  is  very 
small,  the  absolute  quantity  the  foetus  obtains  may  be  very  great  by 
accumulation  ;  this  liquor  contains  salts,  sodium  and  calcium  phosphates, 
which  are  important  for  the  development  of  the  fetus. 

Ahlfeld1  concludes  from  the  examination  of  the  meconium  that  the  foetus 
swallows  considerable  quantities  of  the  amnial  fluid.  This  is  a  physiological 
process  ;  he  has  found  the  amnial  fluid  albuminous  in  several  cases,  ranging 
from  twenty  to  fifty  per  cent,  albumin.  His  tests  were  nitric  acid  and  heat. 

He  believes  that  the  albumin  of  the  amnial  fluid  is  nutriment  for  the  foetus, 
and  by  an  elastic  bag  applied  over  the  mother's  abdomen  at  the  location  of  the 
child's  back,  he  demonstrated  movements  of  the  child's  thorax  in  the  uterus, 
which  he  considered  those  of  deglutition. 

Mekus2  has  met  with  an  instance  supporting  the  belief  that  the  foetus  swallows 
the  liquor  amnii,  in  the  case  of  a  child  who  could  not  retain  fluid  swallowed  ; 
it  died  of  inanition,  and  was  poorly  developed  at  birth.  On  examination,  the 
cesophagus  was  impervious  at  its  middle.  It  was  noticeable  that  the  liquor 
amnii  was  very  abundant  at  birth.  The  case  is  virtually  a  ligation  of  the 
cesophagus  in  the  living  foetus ;  result,  a  poorly  developed  and  nourished  foetus, 
no  evidence  of  liquor  amnii  in  the  digestive  tract,  and  an  abnormal  abundance 
in  utero. 

Undoubtedly,  materials  present  in  the  amnial  liquor  have  been  found 
in  the  stomach  and  intestines  of  the  foetus,  and  thus  it  is  proved  this 
liquor  may  be  swallowed,  but  it  is  not  proved  that  this  is  the  rule,  and 
up  to  the  present  most  have  regarded  it  as  the  exception.  Moreover, 
monsters  in  which  the  mouth  is  absent  are  born  well  developed,  and 
therefore  the  entrance  of  amnial  liquor  into  the  alimentary  canal  is  not 
essential  to  nutrition.  Further,  as  pleasantly  remarked  by  Pinard,  the 
same  physiologists  who  assert  the  nutrition  of  the  foetus  by  the  amuial 
liquor,  also  hold  that  the  foetus  passes  urine  into  this  liquor,  and  it  is 
singular  if  such  a  fluid  contributes  to  its  nourishment.3 

The  permanent  and  certainly  the  chief,  if  not  the  only,  nutritive 
supply  of  the  fetus  is  secured  through  the  placenta — other  means  are 
only  temporary  or  secondary;  during  the  formation  of  this  organ  chorial 
villi,  especially  those  which  contribute  to  its  structure,  the  chorion  fron- 
dosum,  supply  nutritiye  material  to  the  embryo.  The  growth  of  the 
new  being  is  much  slower  before  than  after  the  development  of  the 

1  Zeitschrift  fur  Geburtshiilfe,  Band  14,  Heft  2. 

2  Centralblatt  ftlr  Gynakologie,  No.  42, 1888. 

3  Preyer,  op,  cit.,  admits  the  fact,  remarking:  However  paradoxical  it  may  appear,  the  foetus 
discharges  urine  into  the  amnion,  and  drinks  it,  with  the  other  constituents  of  the  amnial  fluid, 
In  quantity  so  much  greater  as  the  term  of  gestation  approaches,  like  the  embryo  of  the  bird 
before  hatching. 

DUhrsenn,  Centralb.  f.  Gynakol.,  1888,  concludes  from  his  investigations  that  in  the  latter  part 
of  the  intra-uterine  life  the  organs  of  the  foetus  function  as  in  extra-uterine  life  ;  and  that  the 
urine  of  the  foetus  from  time  to  time  is  emptied  into  the  amnial  fluid.  He  believes  the  nutrition 
of  the  foetus  is  dependent  solely  upon  the  placenta,  and  that  amnial  liquor  is  produced  by  fcetal 
excretion. 


THE  EMBRYO  AXD  FCETUS.  155 

placenta,  the  foetus  increasing  in  weight  during  the  last  six  weeks  of 
pregnancy  to  an  amount  equal  to  that  which  it  attained  in  the  first  five 
months.  Foetal  nutrition  has  been  compared  to  that  of  a  vegetable 
parasite,  which  takes  from  the  circulatory  vessels  of  the  plant  on  which 
it  is  developed  the  materials  necessary  for  its  growth. 

Reference  has  previously  been  made  to  the  fact  that  the  solutions  of 
various  substances  may  pass  from  the  maternal  to  the  foetal  blood.  The 
following  are  the  conclusions  of  Preyer1  in  regard  to  the  reciprocal 
relation  of  the  maternal  and  foetal  blood  : 

1.  Very  many  substances  in  solution,  easily  diffusible,  can  pass  from  the  blood 
in  the  sinuses  of  the  maternal  portion  of  the  placenta  into  the  capillaries  of  the 
villi  of  the  foetal  portion  of  the  same  placenta. 

2.  That  oxygen  certainly  passes  from  the  haemoglobin  of  the  blood  globules  of 
the  mother  in  the  placenta,  to  the  haemoglobin  of  the  blood  globules  of  the  foetus 
in  the  capillaries  of  the  villi,  as  long  as  there  is  a  sufficient  quantity. 

3.  That  some  substances  in  solution,  as  the  sodi-indigosulphite  and  the  potassic 
iodide,  can  be  directly  eliminated  from  the  mother  into  the  amnial  liquor  without 
entering  the  blood  of  the  foetus. 

4.  That  soluble  substances  easily  diffusible  can  pass  abundantly  from  the  blood 
of  the  capillaries  of  the  villi  into  the  blood  of  the  sinuses  of  the  maternal  por- 
tion of  the  placenta. 

5.  That  oxygen  certainly  passes  from  the  haemoglobin  of  the  blood  globules  of 
the  foetus  in  the  placenta  to  the  haemoglobin  of  the  blood  globules  of  the  mother, 
if  the  maternal  blood  contains  but  a  minimum  or  no  trace  of  the  oxygen. 

6.  That  some  substances  which  are  soluble  may  pass  from  the  amnial  liquor, 
probably  in  small  quantity,  into  the  blood  of  the  mother. 

7.  That  formed  elements  cannot,  unless  extremely  small,  probably  pass   in 
absolutely  intact  placentas,  and  that  even  then  the  transmission  does  not  take 
place  uniformly,  but  only  in  certain  conditions,  sometimes  dependent  upon  the 
organization,  as  in  sheep,  sometimes  in  anomalous  states,  possibly  increase  of 
blood  pressure,  or  by  means  of  diapedesis  of  leucocytes. 

8.  That  it  has  not  been  conclusively  proved  that  formed  elements  migrate  from 
the  blood  of  the  foetus  into  the  maternal  blood  in  the  placenta,  but  such  passage 
is  possible. 

From  what  has  been  proved  as  to  the  action  of  atropine,  the  natural 
conclusion  is  that  soluble  salts  of  opium  will  readily  pass  from  the 
maternal  to  the  foetal  blood.  Two  milligrammes  of  atropine  were  given 
hypodermatically  to  a  woman  three  hours  before  delivery;  the  child  was 
born  with  dilated  pupils  which  did  not  react  to  light.  So,  too,  the  belief 
is  probable  that  a  woman  who  is  an  opium-eater  is  liable  to  give  birth 
to  a  child  affected  by  morphine;  it  is  possible,  too,  more  remote  injury 
may  result. 

In  one  case  in  which  morphine  was  administered  to  a  pregnant  woman 
by  hypodermatic  injection,  the  foetal  pulse  became  less  frequent  and 
arrhythmic. 

It  has  been  shown  by  Porak  that  when  fifteen  grains,  one  gramme,  of 
quinine  were  given  to  a  woman  in  labor,  the  urine  in  the  child,  born  an 
hour  and  a  half  afterward,  showed  the  presence  of  quinine.  Runge  gave 
to  women  during  several  of  the  last  days  of  pregnancy  half  a  gramme 
daily  of  muriate  of  quinine,  and  in  almost  all  cases  quinine  was  found 
in  the  foetal  urine.  Now  if,  as  is  alleged  by  some  observers,  the  child 

i  On.  cit. 


156  PHYSIOLOGY  OF  PREGNANCY. 

may  suffer  from  intermittent  fever  while  in  the  uterus,  obviously  there 
is  every  reason  to  believe  that  the  disease  may  be  cured  by  giving 
quinine  to  the  mother. 

Occasional  cases  in  which  intra-uterine  vaccination  has  succeeded, 
and  the  transmission  of  certain  diseases  believed  to  depend  upon  germs, 
such  as  syphilis,  variola,  rubeola,  scarlatina,  etc.,  from  the  mother  to 
the  foetus,  testify  to  the  passage  of  micrococci  from  the  maternal  to  the 
foetal  blood. 

CIRCULATION.  The  circulation  in  intra-uterine  life  passes  through 
two  important  phases,  while  a  third  is  entered  upon  at  the  close  of  that 
life.  The  first  is  very  brief,  and  depends  upon  the  formation  of  the 
umbilical  vesicle ;  it  is  called  the  vitelline  circulation.  The  heart,  still 
a  straight,  tubular  cavity,  gives  oif  from  each  end  two  vessels ;  the  two 
superior  are  the  first  aortic  arches,  and  the  inferior  are  the  omphalo- 
mesenteric  veins.  By  the  heart's  systole  the  blood  entering  the  aortic 
arches  passes  first  into  the  body  of  the  embryo,  then  into  the  omphalo- 
mesenteric  or  vitelline  arteries,  which  carry  it  to  the  vascular  area  of  the 
vesicle ;  from  there  it  enters  the  venous  sinus,  situated  at  the  periphery 
of  that  area.  The  omphalo-mesenteric  veins  are  formed  by  branches 
originating  at  the  sinus,  and  empty  the  blood  thus  collected  into  the 
heart  during  its  diastole. 

Second,  or  Placental  Circulation.  The  vitelline  is  superseded  at  the 
beginning  of  the  third  month  by  the  placental  circulation.  The  heart 
is  developed  into  an  organ  of  four  cavities,  and  externally  presents  the 
form  of  the  adult  heart ;  internally  there  are  important  differences. 
The  most  important  of  these  differences  is  that  the  septum  between  the 
auricles  is  imperfect ;  it  hag  a  large  opening,  described  by  Galen,  but  to 
which  the  name  of  Botal  has  been  given ;  it  is  also  called  the  foramen 
ovale.  Furthermore,  the  Eustachian  valve  situated  at  the  entrance  of 
the  inferior  vena  cava  is  remarkably  developed,  so  that  it  turns  the  cur- 
rent of  blood  coming  through  the  latter  vessel  into  the  auricle  to  the 
foramen  ovale,  and  thus  into  the  left  auricle.  Two  important  structures 
must  also  be  mentioned  before  describing  the  circulation,  the  venous 
duct  and  the  arterial  duct,  ductus  venosus  and  ductus  arteriosus ;  the 
former  connects  the  umbilical  vein  with  the  inferior  vena  cava ;  the 
latter,  the  ductus  arteriosus,  which  appears  as  if  a  continuation  of  the 
pulmonary  artery,  connects  the  artery  with  the  aorta  at  a  point  of  the 
arch  just  below  the  origin  of  the  arteries  of  the  head  and  upper  limbs. 

The  blood,  purified  and  rendered  fit  for  nutrition  in  the  placenta,  is 
brought  to  the  foetus  by  the  umbilical  vein,  which  enters  at  the  umbil- 
icus ;  the  greater  part  of  the  blood  passes  at  once  by  the  ductus  venosus 
into  the  ascending  vena  cava,  where  it  mixes  with  the  blood  brought 
from  the  lower  limbs,  the  pelvis  and  the  kidneys ;  a  small  part  passes 
to  the  liver,  and  on  the  other  hand  blood  from  the  hepatic  veins 
empties  into  the  cava.  These  various  collections,  chiefly  of  course  that 
coming  from  the  placenta,  make  the  common  stream  which  is  carried  by 
the  vena  cava  into  the  right  auricle,  but  the  stream  is  turned  by  the 
Eustachian  valve  through  the  right  into  the  left  auricle,  from  which  it 
passes,  as  in  post-uterine  life,  into  the  left  ventricle.  The  heart  now 
contracting,  the  contained  blood  is  sent  from  the  left  ventricle  into  the 


THE  EMBRYO  AND  FOETUS. 


157 


aorta,  from  the  right  into  the  pulmonary  artery.  The  blood  which 
enters  the  aorta  from  the  left  ventricle  passes  chiefly  to  the  head  and 
upper  limbs ;  that  which  goes  into  the  pulmonary  artery  being  needed 
in  only  small  amount  by  the  inactive  lungs,  and  these  organs  incapable 
of  exercising  their  function,  the  blood  does  not  need  them,  therefore 
is  in  greater  part  carried  by  the  ductus  arteriosus  into  the  aorta ;  as 


FIG.  95. 


DIAGRAM  OF  THE  CIRCULATORY  ORGANS  OF 

THE  HUMAN  FCETUS  AT  Six  MONTHS. 
RA.  Right  auricle.  RV.  Right  ventricle. 
LA.  Left  auricle.  Ev.  Eustachian  valve.  L. 
Liver.  K.  Left  kidney.  I.  Part  of  small  intes- 
tine, a.  Aortic  arch.  a'.  Its  dorsal  part.  a". 
Posterior  end  of  abdominal  aorta,  vcs.  Supe- 
rior vena  cava.  vci.  Inferior  vena  cava  near 
its  junction  with  the  right  auricle,  vci.  Pos- 
terior part  of  vena  cava.  s.  Subclavian  ves- 
sels, j.  Right  jugular  vein.  c.  common  car- 
otid arteries  ;  the  four  dotted  arrow-lines  indi- 
cate the  course  of  the  circulation,  da.  Ductus 
arteriosus ;  an  arrow-line  starting  at  vci  indi- 
cates the  course  of  blood-flow  from  the  inferior 
cava  through  the  foramen  ovale.  hv.  Hepatic 
veins,  vp.  Vena  portse.  x  to  vci.  The  ductus 
venosus.  uv.  Umbilical  vein.  ua.  Umbilical 
arteries,  uc.  Umbilical  cord,  i  i'.  Iliac  ves- 
sels. (ALLEN  THOMPSON.) 


the  ductus  venosus  transmitted  a  purified  blood,  so  the  ductus  arteriosus 
conveys  an  impure  blood.  The  aorta,  after  the  ductus  arteriosus  has 
emptied  its  supply  into  it,  contains  blood  from  both  the  left  and  the 
right  heart,  and  transmits  this  mixed  blood  to  the  organs  situated 
below,  to  the  lower  limbs,  and  by  the  umbilical  arteries  to  the  placenta. 
The  blood  which  was  expelled  from  the  right  ventricle  had  been  re- 
ceived from  the  descending  vena  cava  through  the  right  auricle,  and  it 


158  PHYSIOLOGY  OF  PREGNANCY. 

was  therefore  an  impurer  blood  than  that  which  was  expelled  simultane- 
ously from  the  left  ventricle ;  thus  it  is  plain  that  the  lower  half  of  the 
body  has  a  blood  less  rich  in  nutritive  materials  than  the  upper  half, 
and  hence  the  greater  development  of  the  latter  than  of  the  former,  a 
development  which  is  necessary  for  the  exercise  of  certain  functions  in 
the  period  of  life  immediately  following  delivery.  The  organ  which 
receives  the  purest  blood  is  the  liver. 

At  birth  that  which  is  often  called  the  third  circulation  is  established. 
With  the  first  inspiration  of  the  newborn  the  blood  flows  in  increased 
quantity  to  the  lungs,  and  the  stream  which  passed  from  the  pulmonary 
artery  to  the  aorta  through  the  ductus  arteriosus  now  goes  into  the 
branches  of  the  pulmonary  artery,  and  the  arterial  duct  is  narrowed, 
and  obliterated  in  two  or  three  days.  The  blood  coming  from  the 
lungs  fills  the  left  auricle,  prevents  that  which  enters  the  right  auricle 
passing  through  the  foramen  ovale ;  this  opening  in  the  wall  between 
the  auricles,  not  being  used,  is  closed,  the  closure  becoming  complete 
some  weeks  after  birth. 

RESPIRATION.  The  placenta  is  the  respiratory  organ  of  the  foetus. 
As  remarked  by  Spiegetberg,  the  mother's  blood  is  for  the  foetus  the 
external  world  from  which  alike  its  respiration  and  nutrition  needs  are 
satisfied.  The  importance  of  a  supply  of  oxygen  for  the  foetus  is  ren- 
dered probable  by  the  abundance  of  haemoglobin  in  its  blood.  Accord- 
ing to  the  investigations  of  several,  the  blood  of  the  mature  foetus  is 
richer  in  haemoglobin  than  is  that  of  the  mother.  Hoesslin  found,  too, 
in  foetal  blood  which  contained  13.72  per  cent,  of  hemoglobin,  there 
were  5.88  millions  of  blood  corpuscles  in  a  cubic  millimetre  of  the 
blood,  a  very  much  larger  number  than  woman's  blood  has.  Preyer, 
from  his  own  investigations,  has  concluded  that  the  haemoglobin  in  the 
pregnant  woman's  blood  is  never  greater,  often  very  much  less,  than  in 
that  of  the  foetus. 

He  also  states  that  important  changes  of  matter  occur  in  the  foetus, 
as  shown  by  the  formation  of  certain  products  which  are  not  obtained 
from  the  mother's  blood,  secretions  from  its  glands,  or  building  up 
permanent  structures ;  exercise  of  voluntary  and  of  involuntary  muscles ; 
the  foetus,  too,  has  a  higher  temperature  than  that  of  the  mother's 
uterus ;  and  all  these  things  indicate  the  fact  that  oxygen  is  necessary 
for  the  foetus.  The  only  source  of  supply  is  the  maternal  blood.  The 
proofs  of  foetal  blood-changes  in  the  placenta,  analogous  to  those  which 
occur  in  pulmonary  respiration,  are  the  difference  of  color  in  the  blood 
coming  from  and  going  to  the  placenta ;  the  fact  that,  if  the  placental 
circulation  be  temporarily  interrupted,  the  blood  in  the  umbilical  vein 
becomes  dark  like  that  in  the  arteries,  and,  if  the  interruption  be  per- 
manent, the  foetus  dies  asphyxiated,  and  the  only  substitute  for  placental 
is  pulmonary  respiration  ;  finally,  spectroscopic  examination  has  proved 
the  presence  of  oxygen  in  the  foetal  blood. 

It  has  been  held  that  the  foetus  requires  but  a  small  quantity  of  oxygen  because 
the  nutritive  changes  are  so  simple  and  its  activity  so  slight.  But  it  should  be 
remembered1  as  to  the  latter  point  that  the  heart  begins  its  action  early,  and 
that  its  pulsations  are  twice  as  frequent  as  in  the  adult ;  that  foetal  movements 

1  Preyer,  op.  cit. 


THE  EMBRYO  AXD  FCETUS.  159 

occur  some  time  before  the  mother  is  conscious  of  them,  and  that  very  many 
take  place  after  she  has  this  consciousness  without  her  recognition,  for  only 
those  affecting  that  part  of  the  uterus  which  is  in  relation  with  the  anterior 
abdominal  wall  cun  be  known  by  her.  In  answer  to  the  statement  that  the 
nutritive  changes  are  slight,  Weiner,1  from  his  study  of  these  changes  in  the 
foetus,  has  concluded  that  there  exists  in  the  foetus,  especially  in  the  last  period 
of  fetal  life,  a  certain  number  of  organs  which  function  as  in  the  newborn.  The 
kidneys  act,  and  this  quite  early,  in  relation  to  certain  known  substances  arti- 
ficially introduced  into  the  foetus,  exactly  as  the  kidneys  of  the  newborn,  and 
very  rapidly  excrete  these  products.  Absorption  by  the  lymphatics  and  rapidity 
of  the  lymph  currents  are  very  energetic  ;  the  intestinal  mucous  membrane  not 
only  absorbs  substances  in  solution,  but  also  fat.  These  facts  connected  with 
that  of  the  active  secretion  of  the  liver,  of  the  skin,  and  of  the  glands  of  the  in- 
testinal mucous  membrane,  as  well  as  the  relatively  pronounced  development  of 
digestion  of  the  stomach,  and  the  fermentation  properties  already  present  in  the 
extracts  of  the  parotid  and  of  the  pancreas,  permit  us  to  admit  with  great  prob- 
ability that  the  secretory  and  absorbent  organs  of  the  foetus  are  capable  of  per- 
forming their  functions,  and  very  probably  do  perform  them,  as  soon  as  their 
anatomical  structure  and  degree  of  development  permit. 

SECRETION.  The  formation  of  the  sebaceous  glands  begins  toward 
the  end  of  the  fourth  month,  and  in  the  fifth  month  their  secretion  is 
manifested,  and  in  the  sixth  month  becomes'  quite  abundant.  The 
vernix  caseosa,  smegma  embryonum,  which  so  generally  covers  the  sur- 
face of  the  embryo,  is  a  whitish  or  yellowish,  inodorous,  adhesive  matter 
composed  of  epidermic  cells,  sebaceous  cells,  and  fat  globules.  The 
epidermic  scales  make  the  greater  part  of  the  mass,  the  amount  of  fatty 
matter  being  relatively  very  small.  Depaul,  who  did  not  disdain  a 
belief  in  nature's  intelligence,  regarded  the  vernix  caseosa  as  a  wise  pro- 
vision to  prevent  osmosis  from  the  fetal  vessels. 

The  sudoriparous  are  developed  somewhat  later  than  the  sebaceous 
glands,  and  probably  do  not  secrete  during  intra-uterine  life,  though  one 
of  the  many  theories  of  the  origin  of  the  liquor  amnii  was  that  it  was 
formed  by  their  secretion. 

That  the  serous  membranes  of  the  foetus  have  their  normal  secretion 
is  shown  by  those  cases  in  which  children  are  born  having  this  secre- 
tion in  excess,  as  in  cases  of  hydrocephalus,  of  hydrothorax,  and  of  ascites. 

The  remarkable  vascular ization  of  the  liver  in  the  fetus  is,  according 
to  Kolliker,  proof  of  its  great  physiological  importance ;  but  he  regards 
its  role  as  an  organ  of  secreting  bile  as  subordinate  to  that  of  producing 
in  the  blood  special  chemical  and  morphological  modifications.  The 
secretion  of  bile  begins  in  the  third  month  ;  a  bile-like  material  is  found 
in  the  fifth  month  in  the  small  intestine,  later  in  the  large  intestine,  the 
precursor  of  meconium.  The  first  excrement  of  the  newborn  has  been 
called  since  Aristole  nnx^viov,  meconium,  from  its  resemblance  to  the 
juice  of  the  poppy.  Its  presence  indicates  not  only  secretion  from  the 
liver,  but  also  the  activity  of  the  intestinal  glands,  and  its  descent  into 
the  lower  portion  of  the  large  intestine  peristaltic  action  of  the  intes- 
tinal canal.  From  the  seventh  to  the  ninth  month  of  fetal  life  it  pre- 
sents, almost  the  same  characters  as  after  birth ;  it  is  homogeneous, 
viscid,  feebly  acid,  without  odor,  having  a  greenish,  sometimes  almost 
black  color;  it  is  composed  of  bile  and  intestinal  secretions  with,  in 
exceptional  cases  according  to  some,  in  all  cases  according  to  others, 

1  Archiv  far  Gynakologie,  1884. 


1 60  PHYSIOLOG  Y  OF  PREGNANCY. 

materials  derived  from  the  amnial  liquor,  such  as  sebaceous  secretion? 
epidermic  scales,  and  fine  hairs. 

Preyer  states  that  Huber  has  described  two  kinds  of  meconium  which  are  fre- 
quently found  in  the  foetal  intestine,  namely,  the  amniotic  meconium,  which  has 
as  its  component  the  swallowed  amniotic  liquor,  and  which  is  yellow-brown,  and 
the  hepatic  meconium,  which  contains  bile  and  is  dark  green.  The  latter  is  also 
characterized  by  the  presence  of  yellow-green  chiefly  ovoidal  bodies  from  0.005 
to  0.03  millimetre  in  diameter,  which  Huber  has  called  meconium  corpuscles. 
The  forensic  proof  of  meconium  may  be  given  by  these  corpuscles ;  they  are  gen- 
erally surrounded  by  mucus,  insoluble  in  ether  and  in  acetic  acid,  but  soluble  in 
potash  solution. 

Discharge  of  the  meconium  prior  to  birth  rarely  occurs  except  as  a 
pathological  manifestation ;  it  is  often  observed  in  children  born  as- 
phyxiated. The  kidneys  are  exercised  during  the  last  half  of  pregnancy ; 
upon  an  autopsy  made  of  a  foetus  dying  during  pregnancy,  it  is  usual 
to  find  urine  in  the  bladder,  and  it  is  not  uncommon  to  see  urine  escape 
from  the  newborn  just  after  delivery,  while  in  some  cases  it  is  expelled 
during  labor;  hydronephrosis  may  occur  in  pregnancy  from  obstruction 
of  the  ureters.  Although  still  in  dispute,  the  probability  seems  to  be 
that  the  foetus  from  time  to  time  discharges  urine  into  the  amnial  liquor, 
for,  in  addition  to  the  presence  of  urea  in  this  liquid,  in  cases  of  imper- 
forate  urethra  the  bladder  is  found  enormously  distended. 

FCETAL  MOVEMENTS.  INNERVATION.  PASSIVE  IDEATION.*  Fcetal 
movements  are  usually  perceived  by  the  mother  some  time  in  the  fifth 
month.  According  to  Preyer,  the  foetus  moves  its  upper  and  lower 
limbs  long  before  the  beginning  of  the  sixteenth  week,  probably  before 
the  twelfth  week.  Many  of  the  movements  of  the  foetus  are  passive, 
caused  by  change  in  the  mother's  position,  by  varying  abdominal  pres- 
sure, by  uterine  contractions,  and  by  external  pressure  upon  the  uterus. 
Others  result  from  changed  conditions  of  the  maternal  blood,  and  they 
are  termed  irritative  movements ;  many  are  reflex,  and  others  impul- 
sive. The  life  of  the  foetus  is  compared  to  that  of  a  dreamless  sleep 
after  birth.  But,  as  Bailly  has  said,  it  is  probable  that  a  vague  and 
obscure  will  intervenes  in  the  production  of  movements  which  the  foetus 
exercises  after  a  change  of  position  of  the  mother,  and  which  appears 
to  have  as  their  object  the  recovery  of  a  comfortable  position  of  which 
the  movement  of  the  mother  has  deprived  the  foetus.  Nevertheless,  this 
view  is  not  supported  by  Preyer. 

The  question  as  to  the  capability  of  the  foetus  receiving  impressions 
upon  the  senses  cannot  be  completely  answered.  As  far  as  sight,  hear- 
ing, and  smell  are  concerned,  no  such  impressions  are  possible.  Preyer 
regards  it  as  probable  that  the  development  of  the  sense  of  taste  is  the 
earliest.  Kussmaul  has  shown  in  one  child  born  at  eight,  in  another 
at  seven  months,  that  impressions  upon  the  gustatory  nerves  were  very 
distinct,  as  proved  by  the  different  expressions  of  face  and  movements 
of  its  muscles,  as  well  as  those  of  the  mouth,  according  as  sugar  or 
quinine  was  placed  upon  the  tongue.  Jacquemier,  Tyler  Smith,  and 

[  Dr.  Mortimer  Granville  very  ingeniously  maintains  "  that  passive  ideation,  or  the  reception  of 
mental  impressions,  which  are  fixed  as  images  in  the  mind,  proceeds  in  utero."  The  argument  is 
interesting  even  if  the  conclusion  be  rejected.  Lancet,  1876,  vol.  ii.  p.  851. 


PLURAL  PREGNANCY.  1(31 

Tarnier  have  each  tried  the  following  experiment  :  The  uterus  of  a 
pregnant  rabbit  being  exposed,  the  foot  of  one  of  the  young  was  seized 
with  forceps  through  the  thin,  transparent  uterine  wall,  and  immediately 
the  animal  withdrew  the  member.  But  this  movement  on  the  part  of 
the  foetal  rabbit  has  been  by  many  regarded  as  simply  reflex,  and  not 
indicative  of  pain,  though  probably  such  interpretation  is  erroneous. 
The  imperfect  development  of  nerve  ends  is  regarded  as  preventing  the 
sensation  of  pain  from  external  impressions  upon  the  foetus.  Never- 
theless, as  stated  by  Tarnier,  during  intra-uterine  life,  especially  at  the 
end  of  pregnancy,  innervation  ought  probably  to  be  almost  as  complete 
as  in  the  newborn.  It  is  probable,  too,  as  suggested  by  Harvey,  there 
are  periods  of  alternate  rest  and  action  in  the  life  of  the  foetus.  Doubt- 
less the  intra-uteriue  exercise  of  the  voluntary  muscles  contributes  to 
their  development,  if  not  to  the  general  development  of  the  foetus. 

Infantile  Atavism,  by  Dr.  Louis  Robinson,  British  Medical  Journal,  December, 
1891 :  "  The  theory  of  Darwin  that  we  are  descended  from  a  tree-climbing 
quadrumanous  ancestor  led  me  to  test  the  power  of  grip  in  infants,  for  this 
seemed  to  be  a  habit  indicating  a  means  of  self-preservation  in  remote  ages, 
which  would  most  likely  be  still  evident,  owing  to  its  supreme  importance  in  the 
past.  The  result  was  that  I  found  that  every  infant,  even  those  prematurely  born, 
had  a  very  notable  grasping  power,  and  that  the  strongest  were  able  to  hang  by 
their  hands  and  support  their  whole  weight  for  over  two  minutes  and  a  half." 

Dr.  Robinson's  investigations  are  referred  to  in  Revue  des  Revues,  1892,  and  it 

is  stated  that  if  a  finger  is  put  upon  the  foot  of  a  suspended  child,  it  tries  to  grasp 

it  with  the  foot.     "  This  instinctive  movement  is  evidently  a  character  derived 

from  the  habitude  of  primitive  races,  which  constitutes  moreover  a  predominant 

'  quality  of  all  quadrumana." 

PLURAL  PREGNANCY.  When  the  uterus  contains  two  or  more 
foetuses  the  pregnancy  is  plural.  If  there  are  two  foetuses,  they  are 
twins;  if  three,  triplets;1  if  four,  quadruplets ;  and  if  five,  quintuplets ; 
and  the  pregnancies  receive  corresponding  names,  double,  triple,  quad- 
ruple, and  quintuple.  There  is  no2  established  case  in  which  a  woman 
gave  birth  to  more  than  five  children  at  one  time.  In  order  that  plural 
pregnancy  can  occur,  a  single  ovary  must  furnish  the  necessary  ovules, 
or  some  may  come  from  each  ovary;  or,  in  case  of  twins,  one  ovisac 
may  contain  two  ovules,  or  one  ovule  two  germs,  or  the  germ  may  split 
into  two  germs. 

Frequency.  According  to  the  investigation  of  G.  Veit  of  13,000,000 
births  in  Prussia,  twins  occur  once  in  88,  triplets  once  in  7910,  and 
quadruplets  once  in  371,126.  In  recent  years  there  are  about  twelve 
authentic  cases  of  quintuplets,  from  various  countries  (Kaltenbach). 
The  frequency  varies  in  different  countries.  Pliny  stated  that  it  was 
greatest  in  warm  climates,  but  modern  statistics  do  not  sustain  this 
theoretical  opinion.  Thus  in  France  and  in  Belgium  there  are  scarcely 

1  Readers  of  Livy's  History  of  Rome  will  recall  the  combat,  iu  the  war  of  the  Romans  and  the 
Albans,  between  the  brace  of  triplets,  three  representing  each  army,  the  Horatii  and  the  Curiatii. 

2  Nevertheless  this  statement  as  to  five  being  the  largest  number  of  fo3tuses  in  the  human  female 
must  be  set  aside,  for  last  year  the  case  of  an  Italian  woman,  who  in  the  fifth  month  of  pregnancy 
miscarried,  expelling  six  foetuses,  was  reported,  and  the  truthfulness  of  the  report  is  generally  con- 
ceded.   See  London  Lancet,  October  20, 1888. 

Soon  after  the  publication  of  this  case  of  sextuplets  in  Italy,  some  patriotic  American  Ananias 
published  in  a  Western  newspaper  an  account  of  a  similar  event  having  occurred  in  the  interior 
of  Texas,  with  a  description  of  the  six  living  children,  stating  also  the  names  that  had  been  given 
them. 

11 


162  PHYSIOLOGY  OF  PREGNANCY. 

ten  twin  births  in  a  thousand  cases  of  labor,  while  in  Denmark  and  in 
Sweden  the  proportion  is  between  fourteen  and  fifteen,  in  Ireland  be- 
tween sixteen  and  seventeen  to  the  thousand.1  It  is  thus  evident  that 
climate  is  not  a  factor  in  determining  the  frequency  of  plural  preg- 
nancies. A  remarkable  difference  in  the  proportion2  of  twin  to  single 
pregnancies  is  found  in  different  Italian  cities.  While  in  Genoa  there 
is  1  to  54,  Milan  1  to  56,  in  Palermo  the  proportion  is  only  1  to  114. 
Between  Genoa  and  Milan  at  one  extreme  and  Palermo  at  the  other,  in 
regard  to  the  relative  frequency  of  twin  pregnancies,  are  placed  Padua, 
Trente,  Turin,  Bologna,  and  Naples. 

Causes.  In  addition  to  climate,  race,  stature,  and  the  great  develop- 
ment of  the  ovaries  have  been  regarded  as  causes  of  pluriparous  preg- 
nancies. But,  whatever  influence  may  be  attributed  to  any  of  these,  the 
chief  causes  are  multiparity  and  heredity.  The  statistics  of  Duncan 
show  that  the  number  of  pluriparous  multipart  is  about  eight  per  cent, 
greater  than  that  of  pluriparous  primi parse ;  those  of  Puech  show  that 
multipart  have  triplets  eight  times  as  often  as  do  prirniparse.  Heredity 
seems  to  be  a  more  potent  cause.  Female  twins  often  give  birth  to 
twins.  A  woman  had  twin  pregnancies  three  times,  her  daughter  had 
two  twin  pregnancies,  and  her  daughter  in  turn  a  twin  pregnancy.  In- 
stances in  which  this  manifestation  of  heredity  was  transmitted  to  the 
male  are  also  recorded.  Leroy  states  that  four  brothers,  in  whose 
family  twin  pregnancies  in  the  parents  of  a  collateral  branch  had  been 
observed,  procreated  twins — three  of  them  twice  each,  and  the  fourth 
four  times. 

The  cases  just  cited  indicate  that  excessive  fecundity,  though  usually 
belonging  to  the  female,  as  a  cause  of  plural  pregnancy,  may  depend 
upon  the  male. 

Sue  mentions  the  case  of  a  man  whose  wife  gave  birth  to  triplets  seven  times 
in  seven  years,  and  then  seducing  his  servant  girl  she  gave  birth  to  triplets.  Nor 
is  the  case  of  the  Russian  peasant,  Feodor  Wassilief,  to  be  omitted.  It  was 
quoted  by  Velpeau  from  Merriman  ;3  this  peasant  was  married  twice,  and  his 
first  wife  had  quadruplets  four  times,  triplets  three  times,  twins  sixteen  times,  in 
all  sixty -nine  children  ;  his  second  wife  had  triplets  twice,  and  twins  six  times, 
making  her  contribution  only  eighteen  to  the  entire  number  of  seventy-seven. 
Moreover,  eighty-four  of  these  children  and  the  father,  who  was  then  eighty-five 
years  old,  were  living  at  the  time  the  English  merchant,  whose  story  Merriman 
publishes,  visited  Russia. 

In  sixty-one  cases  of  twin  pregnancy,  analyzed  by  Kleinwachter,  the 
youngest  mother  was  nineteen,  the  oldest  forty-one  years  ;  in  67^^-  the 
pregnancies  occurred  in  women  between  twenty-three  and  twenty-nine 
years  of  age,  a  fact  which  does  not  sustain  Matthews  Duncan's  view 
that  "  plariparity  is  an  unnatural  or  abnormal  condition  connected  with 
sterility  by  being  observed  in  the  sterile  ages,  or  ages  of  weakness  or 
imperfection  of  the  reproductive  power.4 

J  Berlin,  Nice-M6dical,  December,  1888,  in  the  study  of  the  births  at  Nice  for  twenty-seven  years, 
in  all  56,505,  finds  that  the  proportion  of  twin  births  was  1  in  75.  of  triplets  1  in  5575. 

2  De  robstetrique  en  Italic.    Millet. 

3  Merriman  apparently  believed  the  story,  for  in  quoting  it  from  the  Gentleman's  Magazine,  1783, 
he  also  quotes  the  following  •  "  The  above  relation,  however  astonishing,  may  be  depended  upon, 
as  it  came  directly  from  an  English  merchant  in  St.  Petersburgh  to  his  relation  in  England,  who 
added  that  the  peasant  was  to  be  introduced  to  the  Empress." 

«  Sterility  in  Women. 


PLURAL  PREGNANCY.  163 

SUPER— IMPREGNATION.  The  question  naturally  suggests  itself  as 
to  whether  the  ovules  which  are  developed  in  plural  pregnancy  are 
fecundated  simultaneously  or  at  different  times.  In  the  case  of  many 
of  the  pluriparous  inferior  auimals  fecundation  is  simultaneous ;  for 
example,  the  boar  impreguates  the  sow  at  a  single  coition.  So  it  may 
be  in  the  human  female,  and  possibly  is  in  the  majority  of  cases.  But 
super- impregnation  is,  arbitrarily  at  least,  divided  into  super-fecunda- 
tion and  super- foetatiou.  By  the  former  is  meant  the  fecundation  of 
one  or  more  ovules  after  one  has  been  fecundated,  that  is,  successive 
instead  of  simultaneous  fecundation  ;  by  super-foetation1  is  meant  fe- 
cundation effected  after  the  uterus  is  occupied  by  the  product  of  concep- 
tion. The  latter  requires  the  occurrence  of  ovulation  several  days, 
weeks,  or  even  months  after  the  ovule  was  liberated  which  was  first 
impregnated. 

That  super-fecundation  may  occur  in  the  human  female,  as  well  as  in 
some  of  the  inferior  animals,  is  certain.  Thus  a  white  woman  has 
twins,  one  a  mulatto,  the  other  white;  or  of  a  black  woman's  twins  one 
is  black,  the  other  a  mulatto.  The  only  rational  explanation  is  that  in 
each  case  each  child  shows  a  different  paternity.  A  mare  may  be 
covered  by  a  stallion,  and  at  an  interval  varying  from  a  few  hours  to 
fifteen  days  is  covered  by  an  ass ;  she  has  twins,  one  a  horse,  and  the 
other  a  mule.  A  bitch  in  heat  is  covered  by  different  dogs,  and  in  her 
litter  the  puppies  may  indicate  different  fathers. 

But  when  super-fecundation  occurs  in  the  human  female,  the  fact  is 
presupposed  that  the  ovules  impregnated  are  liberated  from  their  ovisacs 
at  the  same  menstrual  period.  Nature  intended  her  to  be  uniparous, 
and  once  fecundation  has  occurred  ovulation2  usually  is  suspended,  so 
that  the  probability  of  super-foetation  is  at  once  opposed  by  a  physi- 
ological reason ;  in  other  words,  there  is  no  ovule  to  be  impregnated. 
This  is  admitted  as  a  law ;  nevertheless,  as  claimed  by  some,  there  may 
be  exceptions. 

There  is,  however,  an  anatomical  argument  derived  from  the  condition 
of  the  uterine  cavity  occupied  by  the  developing  ovum  ;  room  for  the 
spermatozoids  to  pass  to  the  ovule,  and  then  space  for  the  entrance  of 
the  latter  into  the  uterus,  present  theoretical  objections.  It  must,  how- 
ever, be  admitted  that  prior  to  the  union  of  the  ovular  and  uterine 
decidua,  which,  as  has  been  before  stated,  occurs  some  time  in  the  fourth 
month,  there  is  no  invincible  anatomical  obstacle  to  a  new  impregna- 
tion occurring.  Nevertheless,  with  the  difficulty  just  mentioned,  and 
with  the  physiological  one  arising  from  the  suspension  of  ovulation 
during  pregnancy,  the  improbability  of  the  occurrence  of  super-foetation 
is  very  great ;  the  strongest  argument  against  super-foetation  is  given 
by  Auvard  in  the  fact  that  in  five-sevenths  of  plural  pregnancies  there 
is  but  a  single  placenta.  Auvard  also  states  that  super-fcetation  is  only 
possible  in  cases  of  a  double  uterus  or  of  an  ectopic  gestation. 

1  In  regard  to  super-foetation  in  animals,  some  curious  and  absurd  statements  are  made  by  He- 
rodotus ;  see  Gary's  translation,  p.  216. 

2  Playfair  gives  the  occurrence  of  menstruation  as  a  proof  of  ovulation.    Before  admitting  such 
an  argument,  it  must  first  be  proved  that  menstruation  does  then  occur ;  next  it  must  be  proved 
that  ovulation  and  menstruation  are  always  necessarily  connected.    A  woman  may  menstruate 
after  her  ovaries  have  been  removed ;  and,  according  to  Play  fair's  argument;  she  necessarily 
ovulates. 


164  PHYSIOLOGY  OF  PREGNANCY. 

The  hypothesis  of  super-foetation  is  proposed,  first,  to  explain  those 
cases  in  which  there  is  simultaneous  expulsion  of  the  products  of  con- 
ception, one  large,  well-developed  foatus,  and  the  other  a  small  and 
feeble  foetus,1  or  the  second  product  may  be  still  in  the  embryonic  con- 
dition. But  twins  usually  differ  in  size  and  vital  power,  and  this  differ- 
ence may  be  so  great  that  the  feeble  ones  dies  soon  after  birth  :  it  may 
depend  upon  the  fact  that  one  was  better  supplied  with  nourishment 
than  the  other  and  prospered  to  the  detriment  of  its  companion,  or  there 
may  have  been  an  inherent  difference  in  the  vitality  of  the  ovules  im- 
pregnated. Where  one  product  was  still  embryonic  and  the  other  well 
developed,  the  answer  is,  the  former  died  early  in  pregnancy  and  re- 
mained without  material  change  until  the  pregnancy  ended. 

But,  second,  the  hypothesis  is  thought  to  explain  the  cases  in  which 
several  days,  weeks,  or,  as  is  alleged  in  some  cases,  months  intervened 
between  the  birth  of  twins.  In  some  of  these  instances  the  mother  was 
found  to  have  a  double  uterus  ;  one  foatus  was  contained  in  one-half,  the 
other  in  the  other  half  of  the  organ ;  and  under  such  circumstances 
possibly  a  considerable  interval  occurred  between  the  impregnations. 
But  most  of  the  cases  correspond  to  a  premature  labor  or  miscarriage 
with  one  foetus,  while  the  other  was  retained  until  full  term  or  somewhat 
beyond. 

Many  of  the  facts  adduced  to  prove  super-foetation  belong  to  a  past 
age,  when  such  marvels  were  more  readily  accepted  than  to-day;  and  as 
a  rule  they  fail  in  the  details  and  thoroughness  of  investigation  neces- 
sary to  establish  their  truth.  "  Few  authors  to-day  believe  in  the  reality 
of  super-foetation."1  DoleVis  suggests  that  super-fecundation — that  is, 
the  fecundation  of  several  mature  ovules  expelled  from  the  ovisacs  at 
the  same  period — may  occur  within  fifteen  days,  or  at  most  three  weeks; 
after  about  this  time  fecundation  seems  impossible. 

FCETAL  APPENDAGES  IN  TWIN  PEEGNANCIES.  Where  two  ovules 
from  different  ovisacs  are  impregnated,  each  foetus  has  its  own  chorion 
and  amnion,  and  originally  the  ovular  decidua  of  each  was  distinct,  but 
the  portion  intervening  between  the  two  sacs  is  absorbed,  so  that  they 
have  a  common  decidua.  The  placentae  may  be  closely  united,  but  there 
is  no  vascular  connection  ;  there  is  entire  independence  as  to  the  circu- 
lation in  each. 

If  there  be  a  single  placenta  with  one  chorion  and  two  amnions, 
either  there  were  two  germs  in  one  ovisac,  or  the  germinal  vesicle  has 
furnished  two  germinal  areas.  The  bloodvessels  of  the  twins  commu- 
nicate in  the  placenta.  (Fig.  96.)  Either  the  twins  are  well  developed, 
or  the  greater  heart  activity  of  one  takes  away  the  nourishment  needed 
by  the  other,  and  the  latter  dies.  The  twins  are  of  the  same  sex.  Most 
rarely  there  are  one  placenta,  one  chorion,  and  one  amnion.  -  The  amnion 
folds  between  the  two  may  have  been  absorbed  because  of  pressure ;  or 
the  origin  of  the  twins  may  have  been  from  the  division  of  a  germ ;  the 
twins  are  of  the  same  sex. 

1  In  a  litter  of  pigs  it  is  not  unusual  to  find  one,  generally  the  last  born,  smaller,  feebler,  and 
more  poorly  developed  than  any  one  of  its  brothers  or  sisters  ;  it  is  commonly  known  as  the  runt  ; 
but  farmers  never  adduce  this  fact  as  a  proof  of  super-foetation. 

*  DoUris. 


PLURAL  PREGNANCY. 


GRAAFIAN  FOLLICLE  WITH  TWIN  OVULES.    (After  v.  HERFF.) 

SEX,  SIZE  OF  TWINS,  COURSE  OF  THE  PREGNANCY.  In  the  great 
majority  of  cases  twins  are  of  the  same  sex,  and  males  predominate  over 
females.  The  united  weights  of  twins  at  birth  is  usually  greater  than 
that  of  a  single  foetus  at  the  same  period  of  development,  but  the  weight 
of  each  is  considerably  below  the  mean ;  generally  one  of  the  twins  is 
larger  and  stronger  than  the  other.  One  of  the  children  may  die  early 
in  the  pregnancy,  and  either  be  expelled  with  its  appendages  and  preg- 
nancy go  on,  or  be  retained  and  the  liquor  amnii  absorbed,  while  it  under- 
goes the  change  called  mummification ;  or  it  may  be  pressed  against  the 
uterine  wall  by  the  other  foetus  and  its  membranes,  so  that  it  is  flattened, 
making  a  thin  mass  called  foetus  papyraeeus.  In  other  cases  the  con- 
dition previously  mentioned  as  to  the  heart  of  one  of  the  twins  having 
greater  power  than  that  of  the  other  may  be  present,  and  the  latter  fail 
in  development,  except  as  to  the  lower  part  of  the  body  and  lower  limbs, 
and  a  monster  known  as  acardia  results,  while  the  former  is  perfectly 
developed. 

Abortions,  polyhydramnios,  and  monstrosities  are  more  frequent  in 
plural  than  in  single  pregnancies ;  acephalous  monsters  are  only  found 
in  the  former. 

Premature  labor  frequently  occurs  in  twin  pregnancies,  its  usual 
cause  being  excessive  distention  of  the  uterus.  Triple  pregnancies 
rarely,  and  quadruple  probably  never,  reach  the  normal  term. 


CHAPTER   VI. 

CHANGES   IN   THE   MATEENAL   ORGANISM. 

THE  changes  in  the  impregnated  ovule  having  been  traced  from  their 
beginning  in  conception  to  their  end  in  the  completely  developed  foetus, 
there  are  now  to  be  considered  the  modifications  which  pregnancy  causes 
in  the  maternal  organism  ;  in  a  word,  to  present  the  natural  history  of 
pregnancy  in  regard  to  the  mother.  The  changes  in  the  maternal 
organism  caused  by  pregnancy  may  be  divided  into  general  and  local. 

GENERAL  CHANGES.  These  chiefly  involve  the  digestive  apparatus 
and  nutrition,  the  heart  and  the  blood,  respiration,  the  nervous  system, 
the  skin,  and  the  urinary  apparatus  and  secretion. 

MORNING  SICKNESS.  Gastric  disturbance  is  an  almost  constant 
phenomenon  manifested  in  the  first  mouth  of  pregnancy.  From  the  fact 
that  nausea  and  vomiting  are  more  frequent  in  the  early  part  of  the  day, 
or  if  occurring  at  other  times  are  usually  more  severe  then,  the  disorder 
is  commonly  known  as  morning  sickness.  In  some  cases  it  may  be  so 
slight  as  scarcely  to  constitute  an  indisposition,  only  a  transient  dis- 
comfort, but  in  others  so  severe  as  to  be  a  grave  disease.  It  may  begin 
soon  after  the  supposed  time  of  conception,  but  more  frequently  at  the 
first  following  menstrual  suppression  ;  in  either  case  it  usually  abates  or 
disappears  some  time  in  the  fourth  month.  In  most  cases  the  desire  for 
food  is  lessened,  and  in  women  whose  nausea  is  great  or  constant  dis- 
gust may  supersede  desire. 

In  a  very  few  cases  pregnancy  seems  from  the  first  to  increase  the 
appetite,  digestion  is  good,  and  the  subject  is  in  better  health  than  usual. 
In  still  others  the  appetite  may  be  capricious,  fickle  as  to  kinds  of  food, 
or  wishing  for  those  articles  which  at  other  times  are  not  cared  for,  or, 
finally,  it  may  be  perverted.  The  whimsical  or  perverted  appetences  of 
pregnant  women,  commonly  known  as  "  longings,"  are  in  some  cases 
assumed,  or  imaginary,  not  real ;  a  primigravida,  for  example,  has  read 
or  heard  stories  of  such  u  longings,"  and  believing  them  natural  to  her 
condition,  the  step  is  but  a  short  one  to  imagining  she  has  them.  In 
the  word  mother-marks  there  is  perpetuated  the  once  popular  belief  that 
if  the  desire  or  longing  of  the  pregnant  woman  for  some  particular 
article  of  food  is  not  gratified,  the  fetus  will  be  marked. 

Pliny  used  the  word  malaria  to  express  the  "  longings  "  of  pregnant  women. 
A  distinction  has  been  made  by  some  between  malaria  and  pica,  the  former  being 
used  to  signify  that  the  appetite  sought  unaccustomed,  but  still  nutritious,  sub- 
stances for  food,  while  in  the  other  there  was  a  complete  perversion  of  the 
appetite,  which  sought  materials,  such  as  chalk  or  charcoal,  that  were  entirely 
indigestible,  or  which  were  repulsive  and  disgusting,  like  feces.  But  this  dis- 
tinction has  not  been  generally  held. 

The  word  pica  is  the  Latin  for  magpie,  and  was  used,  Gardien  says  ( ft-aiti 
Complet  d'Accouchements),  to  signify  the  whimsicalities  of  pregnant  women  and  of 


CHANGES  IN  THE  MATERNAL  ORGANISM.  167 

chlorotic  girls,  because  there  was  thought  to  be  an  analogy  between  their  appe- 
tites and  the  parti-colored  plumage  of  the  magpie,  or  its  inconstancy  as  shown 
in  hopping  from  one  to  another  branch  of  the  tree  on  which  it  is  perched. 

Strange  stories  have  been  told  of  these  "longings,"  as,  for  example,  of  a  preg- 
nant woman  who  longed  for  salted  herring,  and  ate  fourteen  hundred  during  her 
pregnancy;  or  of  another  who  longed  for  a  bite  of  the  baker's  shoulder,  and  the 
kind  husband,  fearing  he  would  lose  his  wife  if  the  longing  were  not  gratified, 
got  the  baker's  consent,  and  she  took  two  bites  ;  and  of  another  who  longed  so 
earnestly  to  eat  her  husband  that  she  killed  him,  ate  heartily  of  his  body,  and 
then  pickled  the  rest  for  future  consumption.1 

In  the  latter  part  of  pregnancy,  before  descent  of  the  uterus  has 
occurred,  and  while  the  fundus  is  pressing  upon  the  stomach,  some 
women  have  a  recurrence  of  gastric  disorder,  but  this  is  slight  and  tran- 
sient. Neither  this  manifestation  nor  that  of  the  earlier  months  should 
be  confounded  with  the  graver  form  of  the  disorder,  which  may  occur 
as  a  symptom  of  albuminuria  and  a  forerunner  of  eclampsia. 

It  is  easy  to  understand,  as  observed  by  Stoltz,  that  the  irregularity 
or  depravation  of  the  digestive  functions  in  the  early  months  of  preg- 
nancy must  cause  imperfect  nutrition.  "  Hence  the  pregnant  woman 
emaciates  in  the  first  month;  her  appearance  is  bad — that  is  to  say,  her 
features  are  drawn,  her  eyes  surrounded  by  dark  circles,  and  her 
expression  becomes  more  or  less  dull.  She  is  sluggish,  melancholy, 
drowsy.  In  a  word,  there  is  developed  a  condition  more  or  less  resem- 
bling chloro-ansemia."  But  the  nausea  generally  ceasing  with  the 
beginning  of  the  fourth  month,  at  least  before  or  by  the  middle  of  this 
month,  foetal  movements  being  recognized  by  the  mother,  all  uncer- 
tainty as  to  her  condition  is  removed,  the  appetite  is  restored,  digestion 
becomes  better,  her  general  condition  is  greatly  improved,  nutritive 
processes  are  quickened,  and  she  gains  in  weight.  This  increase  of 
weight  is  greatest  in  the  last  three  months  of  pregnancy,  being,  accord- 
ing to  the  investigations  of  Hecker  and  Gassner,  from  one  kilogramme 
and  a  half  to  two  kilogrammes  and  a  half  each  month.  A  woman's 
weight  is  about  one-thirteenth  greater  at  the  end  than  it  was  at  the 
beginning  of  pregnancy.  "  In  the  cases  when  the  weight  lessened  in 
the  eighth  or  ninth  mouth  Gassner  ascertained  conditions  unfavorable 
to  nutrition ;  for  example,  the  death  of  the  foetus  and  its  retention  in 
the  uterus.  This  phenomenon^  observed  in  three  instances,  always  had 
as  its  consequence  a  diminution  of  the  weight  of  two  to  three  kilo- 
grammes in  a  period  of  eight  to  fifteen  days."2 

CHANGES  IN  THE  BLOOD  AND  CIRCULATORY  APPARATUS.  The 
blood-changes  resulting  from  the  pregnant  state  relate  to  quantity  and 
quality.  There  is  a  decided  increase  in  the  amount  of  blood,  this  increase 

1  In  the  following  passage,  from  Bartholomew  Pair,  these  "longings  "  are  well  satirized  :  "Oh, 
yes !  Win ;  you  may  long  to  see,  as  well  as  taste,  Win  :  how  did  the  'pothecary's  wife,  Win,  that 
longed  to  see  the  Anatomy,  Win? — or  the  lady,  Win,  that  desired  to  spit  i'  the  great  lawyer's 
mouth,  after  an  eloquent  pleading?" 

The  universal  and  deep-rooted  popular  belief  in  the  "longings"  of  the  pregnant  woman,  and 
the  necessity  for  their  gratification,  have  no  more  striking;  illustration  than  isigiven  in  one  of  the 
Coventry  Miracle  Plays  (Ancient  Mysteries  Described ;  Especially  the  English  Miracle  Plays,  by 
William  Hone,  London,  1823).  Mary  and  Joseph  are  passing  along  the  road,  when  they  come  to  a 
cherry-tree  laden  with  ripe  fruit;  she  •'  longs"  for  the  cherries,  which  he  refuses  to  get  for  her, 
when  the  tree  miraculously  bends  its  branches  to  her,  and  her  wish  is  at  once  gratified.  Hone 
states  that  a  Christmas  carol  founded  upon  the  play,  and  in  which  this  incident  is  fully  given, 
was  in  his  day  sung  in  London  and  many  parts  of  England.  There  was  not  a  thought  of  irrever- 
ence in  play  or  in  song.  The  event  was  regarded  as  natural  and  necessary. 

2  Tarnier. 


168  PHYSIOLOG  Y  OF  PREGNANCY. 

beginning  about  the  middle  of  pregnancy.  When  we  consider  the 
greater  nutritive  demands,  especially  for  the  foatus  and  its  appendages 
and  for  the  uterus,  and  the  larger  area  of  the  circulation,  an  increase  in 
the  quantity  of  the  blood  is  obviously  necessary.  It  has  until  quite 
recent  years  been  held  that  in  the  course  of  pregnancy  the  watery  por- 
tion of  the  blood  became  more  abundant,  the  fibrin  and  the  white  cor- 
puscles increased,  and  the  red  corpuscles  lessened.  But  the  researches 
of  Fehling,1  Reinl,  and  Richard  Schroder  prove  that  the  haemoglobin 
and  the  red  corpuscles  are  notably  increased.  Vinay,2  while  admitting 
that  in  the  majority  of  cases  the  blood  becomes  richer,  the  globules 
more  numerous,  their  globular  value  augments,  and  these  modifications 
confirm  the  theory  of  plethora,  so  long  admitted  by  physicians,  that  this 
globular  richness  undergoes  exceptions,  and  in  some  women  pregnancy 
is  the  occasion  of  auaamia. 

Hypertrophy  of  the  heart,  as  a  constant  phenomenon  of  pregnancy,  was 
first  made  known  by  Larcher  in  1857.  This  hypertrophy,  like  that  ot 
the  uterus,  disappears  after  the  pregnancy  has  ended.  By  Blot  the 
increase  in  the  weight  of  the  heart  was  stated  to  be  about  one-fifth. 
Lohlein3  and  Gerhardt  have  denied  cardiac  hypertrophy  in  pregnancy. 
The  recent  investigations  of  Dreysel,  in  the  Munich  Pathological  In- 
stitute, prove  that  there  is  a  slight  eccentric  hypertrophy  of  the  heart, 
chiefly  of  the  left  side. 

The  greater  activity  of  the  circulation  is  manifested  by  increased 
arterial  tension.  The  veins,  too,  are  fuller,  and  varicose  enlargements 
frequent. 

RESPIRATION.  The  base  of  the  thorax  is  increased  during  preg- 
nancy, while  its  vertical  and antero-posterior  measurements  are  lessened; 
but  it  seems  doubtful  if  the  former  increase  in  the  pulmonary  capacity 
compensates  for  the  loss  resulting  from  the  two  other  changes  men- 
tioned. The  pregnant  woman,  when  the  uterus  has  risen  so  high  as 
to  interfere  with  the  normal  descent  of  the  diaphragm  in  inspiration, 
suffers  from  hurried  breathing,  or  from  dyspnoaa,  when  making  great 
bodily  exertion,  as  in  rapid  walking  or  ascending  steps.4 

The  quantity  of  carbonic  acid  eliminated  by  the  lungs  constantly 
increases  as  pregnancy  advances. 

URINE  AND  URINARY  APPARATUS.  The  blood  now  being  increased, 
as  well  as  the  arterial  tension, 'the  quantity  of  urine  secreted  is  greater. 
But  this  increase  of  urine  is  almost  exclusively  of  its  watery  portion  ; 
with  the  exception  of  the  chlorides,  the  solid  constituents  progressively 
lessen  with  the  duration  of  the  pregnancy.  The  lessened  elements  are 
phosphates,  sulphates,  urates,  uric  acid,  creatin  and  creatiuin  ;  and  the 
suggestion,  which  in  part  seems  quite  probable,  has  been  made  that  the 
lessened  elimination  of  these  in  the  urine  may  result  from  their  being 
used  in  fetal  development. 

1  Runge,  Geburtshulfe,  second  edition,  1894,  and  Kaltenbach,  Lehrbuch  der  Geburtshulfe,  1893. 

2  Traite  des  Maladies  de  la  Grossesse,  1894. 

8  Lehrbuch  der  Geburtshulfe,  second  edition,  1893. 

4  This  fact  would  seem  conclusive  as  to  lessened  pulmonary  capacity.  Nevertheless  the  measure- 
ments made  by  Kuchenmeister,  Fabius,  Wintrich,  and  more  recently  by  Vegas  in  Winckel's  clinic, 
show  that  there  is  no  change  even  in  the  latter  months  of  pregnancy. 


CHANGES  IN  THE  MATERNAL  ORGANISM.  169 

Kyestein,  from  the  Greek  wr/aig,  pregnancy,  is,  as  described  by  Nauche  in  1831, 
a  white,  grumous,  soft  pellicle  found  upon  the  urine  of  a  pregnant  woman  about 
thirty-six  hours  after  it  has  been  passed  ;  about  the  fifth  day  this  pellicle  breaks 
up  and  falls  to  the  bottom  of  the  vessel.  The  late  Dr.  Elisha  Kent  Kane,  who 
became  so  famous  as  an  Arctic  explorer,  in  1841  verified  by  observations  at  the 
Philadelphia  Hospital  the  statements  of  Nauche  and  other  foreign  investigators 
as  to  the  presence  of  kyestein  in  the  urine  of  pregnant  women,  and  as  to  its 
character.  Subsequent  investigations,  however,  have  proved  that  kyestein  is  not 
an  organic  substance,  but  is  chiefly  composed  of  ammonio-magnesium  phosphates, 
vibrions  and  monads ;  it  may  be  found  in  the  urine  of  the  non-pregnant  as  well 
as  in  the  urine  of  pregnant  women,  and  also  in  that  of  the  male. 

Renal  congestion  may  result  from  compression,  and  albuminuria  fol- 
low. According  to  Spiegelberg,  it  is  not  rare  to  find  albumin  in  the 
urine,  especially  during  the  latter-  weeks  of  pregnancy,  and  he  regarded 
it  as  usually  depending  upon  a  vesical  catarrh.  The  results  of  observa- 
tions made  in  the  Philadelphia  Hospital  lead  me  to  believe  that  albumin 
is  not  found  in  the  last  month  of  pregnancy  oftener  than  in  one  out  of 
ten  women.  In  a  very  small  proportion,  probably  not  more  than  6 
per  cent.,  sugar  is  present  in  the  urine  in  the  last  weeks  of  pregnancy. 

The  close  attachment  of  the  bladder  to  the  uterus  produces  changes 
of  position  of  the  former  corresponding  with  those  of  the  latter  organ  ; 
thus,  in  the  earlier  weeks  of  pregnancy,  the  bladder  descends  somewhat 
with  the  uterus,  and  its  full  expansion  is  prevented  ;  hence  vesical  irri- 
tability is  one  of  the  first  symptoms  of  pregnancy.  Observation  shows 
that  the  majority  of  pregnant  women  suffer  from  some  disturbance  or 
disorder  of  the  bladder,  the  liability  being  greater  in  primigravidse  than 
in  multigravidse. 

CHANGES  IN  THE  SKIN.  Pigment  deposits  may  occur  upon  the  face, 
the  forehead,  the  mamma?,  the  labia,  and  upon  the  abdominal  walls. 
Pigmentation  of  the  mammae  and  nymphee  will  be  described  in  another 
place.  Irregular  yellowish-brown  patches  upon  the  forehead  and  the 
face  form  what  has  been  called  the  mask  of  pregnancy.  The  intensity 
of  the  color1  varies  in  different  subjects ;  the  patches  become  less  dis- 
tinct after  pregnancy,  but  do  not  disappear,  and  are  renewed  at  each 
succeeding  pregnancy.  In  most  cases  a  pigment  deposit  is  found  in 
the  median  line  of  the  abdominal  wall ;  it  is  more  marked  in  brunettes 
than  in  blondes,  but  is  very  indistinct  in  those  having  red  hair.  The 
pigment  band  is  two  or  three  fingers'  breadth,  and  reaches  from  the  mons 
veneris  to  the  umbilicus,  in  some  cases  to  the  xiphoid  cartilage,  and 
then  there  is  a  ring  of  discoloration  about  the  umbilicus,  the  umbilical 
areola  ;  the  band  is  more  distinct  below  than  above.  No  satisfactory 
explanation  of  these  discolorations  has  been  given,  though  they  probably 
are  the  consequence  of  a  more  rapid  destruction  of  red  corpuscles.  Dr. 
Barnes2  has  suggested  that  the  pigmentation  of  pregnancy  is  dependent 
upon  a  functional  modification  of  the  supra-renal  capsules,  while  Jeannin3 

1  "  Bomare,  in  article  cited  by  Blumenbach,  mentions  a  French  peasant  whose  abdomen  became 
entirely  black  during  each  pregnancy  ;  and  Camper  gives  an  account  of  a  female  of  rank  who 
began  to  be  brown  as  soon  as  she  was  pregnant,  and  before  the  end  was  as  black  as  a  negress. 
After  delivery  the  color  gradually  disappeared.    Le  Cat  relates  the  case  of  a  female  who  was 
similarly  affected  in  the  face  only  during  three  successive  pregnancies  ;  and  Gardien  has  recorded 
another."    (Laycock  on  the  Nervous  Diseases  of  Women.) 

2  Transactions  of  the  American  Gynecological  Society,  vol.  i. 
s  Gazette  Hebdom.,  1868 


170  PHYSIOLOGY  OF  PREGNANCY. 

attributed  it  to  the  amenorrhoea  of  pregnancy.  Localized1  eczema  and 
seborrhcea,  especially  upon  the  face  and  head,  are  often  seen. 

The  anterior  wall  of  the  abdomen  becomes  thinner.  The  enlarged 
uterus  causes  it  to  project,  the  projection  being  much  more  marked 
when  the  woman  is  standing  than  when  she  is  lying  ;  thus,  according  to 
Schroder,  the  measurement  at  the  end  of  the  pregnancy,  from  the 
xiphoid  cartilage  to  the  pubic  joint,  is,  if  she  be  standing,  eighteen 
inches  and  a  half,  47  centimetres,  but  if  she  be  lying,  it  is  a  little  less 
than  sixteen  inches,  40  centimetres. 

During  the  first  three  months  of  pregnancy  the  umbilical  depression 
is  slightly  increased,  or  unchanged  ;  in  the  fifth  month  it  has  become 
less,  and  at  seven  months  has  disappeared ;  in  the  last  two  mouths 
there  is  more  or  less  umbilical  protrusion. 

Striae,  strice  gravidarum,  linece  albicantes,  or  cicatrices  of  pregnancy, 
usually  occur  in  the  first  pregnancy,  and  it  is  not  uncommon  for  new 
ones  to  be  observed  in  subsequent  pregnancies.  These  stria?  are  in 
most  cases  abdominal,  but  in  some  are  found  upon  the  hips  and  thighs, 
and  then  are  not  connected  with  the  pregnant  state,  or  they  are  upon 
the  breasts  ;  the  last  in  most  instances  originate  after  labor.  When 
recent  they  have  a  pinkish  or  bluish-red  tint,  but  after  labor  they 
become  white,  or  pearl-colored  ;  generally  their  surface  is  depressed, 
but  in  some  cases,  as  the  result  of  serous  effusion  from  compression  of 
the  epigastric  vein,  it  is  prominent.  They  are  caused2  by  partial  or 
complete  atrophy  of  the  lymph  spaces,  partial  atrophy  of  the  skin,  and 
longitudiual  arrangement  of  the  fibres  of  connective  tissue.  They  are 
generally  in  four  concentric  zones,  the  centre  being  an  inch  or  more 
below  the  umbilicus.  They  do  not  usually  become  well-marked  until 
the  seventh  month,  and  in  the  primiparous  are  a  sign  of  some  value  in 
the  diagnosis  of  pregnancy  ;  nevertheless  they  are  absent  in  from  six  to 
ten  per  cent,  of  pregnant  women.  Montgomery3  mentions  the  case  of 
a  woman  who  had  borne  five  children,  nursing  three  of  them,  and  yet 
there  were  no  cicatrices.  According  to  Crede  they  are  absent  in  10  per 
cent.,  and  according  to  Hecker  in  6  per  cent.  Schultze  has  found  them 
in  36  per  cent,  of  women  who  have  not  borne  children. 

CHANGES  IN  THE  NERVOUS  SYSTEM.  Pregnancy  increases  the 
nervous  sensibility,  and  hence  numerous  reflex  disturbances  may  occur. 
There  may  be  occasional  rigors,  dizziness,  flashes  of  heat,  hysterical  dis- 
orders, fainting,  disturbances  of  special  senses,  especially  of  sight  and 
hearing,  and  neuralgic  affections,  those  of  the  teeth  being  very  frequent. 
In  regard  to  the  mental  state,  the  general  rule  is  women  become  more 
sensitive,  and  in  the  majority,  probably,  despondent  feelings  prevail. 
Dr.  Hodge  has  remarked  that  "  gestation  has  a  very  happy  influence 
upon  the  minds  of  a  few  women  ;  they  feel  well,  their  mental  powers 
are  active,  their  imagination  excited,  so  that  they  become  more  inter- 
ested in  reading,  writing,  or  other  intellectual  pursuits  than  at  any  former 
period;  they  become  more  cheerful,  and  more  interested  in  the  ordinary 
affairs  of  life."  Unfortunately  this  picture  is  of  the  few.  A  larger 

1  Spiegelberg. 

2  See  contribution  by  Dr.  Busey,  Transactions  American  Gynecological  Society,  vol.  iv. 
2  Signs  of  Pregnancy. 


CHANGES  £V  THE  MATERNAL  ORGANISM.  171 

number  have  needless  anxiety  as  to  their  safely  passing  through  labor 
and  as  to  the  life  and  health  of  their  offspring.  The  majority,  however, 
as  the  pregnancy  goes  on,  become  reconciled  to  their  condition,  and  pati- 
ently wait  its  end,  while  some  indeed  look  forward  to  becoming  mothers 
with  joyful  expectation.  Even  in  those  women  whose  pregnancy  is 
marked  by  despondency  and  anxiety,  it  is  not  unusual  as  it  approaches 
its  end  to  find  the  cloud  lifting,  and  they  are  ready  to  meet  their  final 
trial  patiently,  bravely,  and  hopefully. 

OSTEOPHYTES — HYPERTROPHIES    OF    VARIOUS     ORGANS.       Before 

describing  the  modifications  of  the  sexual  organs  caused  by  pregnancy, 
brief  reference  will  be  made  to  some  other  changes.  Osteophyte  was 
the  name  given  by  Lobstein  to  a  formation  originating  from  the 
bone  or  from  the  periosteum.  Rokitansky,  in  1838,  found  in  post- 
mortem examinations  that  in  more  than  one-half  of  pregnant  women 
there  were  growths  upon  the  internal  table  of  the  cranial  bones,  and  ex- 
ternal to  the  dura  mater,  bone-like  formations  which  he  called  osseous 
neoplasms  or  osteophytes.  Similar  deposits  have  been  found  upon  the 
inner  surfaces  of  the  pelvic  bones  of  women  dying  in  childbed.  Osteo- 
phytes have  no  effect  upon  the  cerebral  functions,  nor  do  they  belong 
exclusively  to  pregnancy,  for  they  have  been  found  in  the  tuberculous. 
In  addition  to  hypertrophy  of  the  heart,  which  has  been  referred  to, 
and  that  of  the  uterus,  which  will  be  hereafter  described,  some  other 
organs,  among  which  are  the  spleen,  the  kidneys,  the  liver,  and  thyroid 
gland,  increase  in  size  in  the  pregnant  woman.  The  increase  in  the 
spleen  is  about  one  ounce  and  a  quarter,  forty  grammes.  Since  Demo- 
critus,  swelling  of  the  neck  has  been  popularly  regarded  as  one  of  the 
signs  of  conception,  and  Cazeaux  has  remarked  that  hypertrophy  of  the 
thyroid  gland,  independent  of  any  local  disease  or  of  endemic  influence, 
is  not  rare  during  pregnacy.  If  the  thyroid  be  hypertrophied  in  a 
pregnancy,  the  hypertrophy  lessens  subsequently,  but  does  not  entirely 
disappear,  and  it  increases  with  each  succeeding  gestation. 

LOCAL  CHANGES.  Under  this  head  it  is  proposed  to  describe  modi- 
fications which  occur  in  the  external  and  internal  genital  organs,  and 
in  the  parts  adjacent  to  them,  in  the  pelvic  joints,  and  in  the  mammary 
glands. 

CHANGES  IN  THE  EXTERNAL,  ORGANS  OF  GENERATION  AND  OF 
THE  VAGINA.  It  is  not  until  about  the  fourth  month  of  pregnancy 
that  changes  in  the  external  genitals  are  noticeable.  The  secretion  of 
the  vulval  glands  is  increased  ;  the  great  and  the  small  lips  are  larger, 
more  elastic,  resisting,  and  darker,  pigmentation  often  being  quite  de- 
cided upon  the  external  surfaces  of  the  labia  majora ;  the  veins  and 
venous  plexuses  are  fuller;  in  some  cases  varicosities  are  present;  the 
vulval  orifice  is  more  open.  A  greater  supply  of  blood  in  the  vagina 
causes  distinct  throbbing  of  the  vaginal  arteries — the  vaginal  pulse — 
which  Osiauder  spoke  of  as  one  of  the  signs  of  pregnancy.  From 
venous  stasis  the  color  of  the  vagina  changes,  becoming  much  darker, 
so  that  it  is  purple  or  of  a  violet  hue,  which  is  regarded  by  Jacquemiu 
and  Kluge  as  an  almost  certain  sign  of  pregnancy ;  its  value,  however, 
is  lessened  by  the  fact  that  a  similar  change  of  color  has  been  observed 
in  menstruation.  The  temperature  of  the  vagina  is  slightly  increased  ; 


172  PHYSIOLOGY  OF  PREGNANCY. 

its  raucous  membrane  is  swelled ;  a  more  abundant  secretion  is  present, 
and  the  papillae  are  larger  and  more  distinct,  so  that  the  surface  may  be 
somewhat  rough.  The  muscular  coat,  especially  in  the  upper  half  of 
the  vagina,  is  hypertrophied.  The  vagina  is  lengthened  by  the  ascent 
of  the  uterus,  but  shortened  again  when  the  uterus  descends,  and  also 
then  greatly  expanded,  admitting  the  entrance  of  the  presenting  part  of 
the  fetus  covered  by  the  uterine  walls. 

CHANGES  IN  THE  PERINEUM.  The  perineum  is  more  freely  sup- 
plied with  blood,  it  is  somewhat  hypertrophied,  and  it  is  gradually  pre- 
pared for  the  great  distention  to  which  it  is  subjected  in  labor.  Tarnier 
states  that  in  many  experimental  applications  of  the  forceps  in  women 
who  died  in  pregnancy,  or  soon  after  labor,  and  in  others  who  died  not 
having  been  pregnant,  he  found  in  the  last  the  perineal  floor  quite  resist- 
ing and  very  liable  to  rupture. 

CHANGES  IN  THE  PELVIC  JOINTS.  These  joints  are  swelled  and 
softened,  and  some  movement  in  the  pubic  joint  can  usually  be  detected  ; 
but  the  opinion  that  in  either  this  or  in  the  sacro-iliac  joints  there  is 
great  increase  of  pelvic  diameters,  facilitating  the  passage  of  the  child, 
is  not  generally  held  by  obstetricians. 

CHANGES  IN  THE  UTERUS.  These  are  the  most  important  of  all  the 
modifications  in  the  maternal  organism  caused  by  pregnancy.  They 
affect  the  structure,  size,  capacity,  form,  weight,  position,  relations,  and 
functions  of  the  uterus.  Some  of  the  modifications  of  the  uterus  may 
occur  independently  of  the  presence  of  the  ovum  in  its  cavity,  for  they 
are  present  in  extra-uterine  pregnancy,  but  they  are  then  limited  in 
degree  and  in  duration.  It  will  be  convenient  to  consider  first  the 
changes  which  occur  in  the  body,  and  then  those  in  the  neck  of  the 
uterus. 

MODIFICATIONS  OF  THE  UTERINE  WALLS.  A  larger  supply  of 
blood  to  the  uterus  causes  increased  growth  of  its  tissues.  The  mus- 
cular fibres  become  relatively  colossal,  increasing  from  seven  to  eleven 
times  in  length,  and  from  two  to  five  times  in  breadth  ;  "embryonic 
muscle  cells,  that  have  been  stored  up  for  the  time  of  need,"  now  grow 
into  larger  and  contractile  forms;  both  hypertrophy  and  hyperplasia 
occur.  The  serous  coat  is  also  developed  in  correspondence  with  the 
general  growth  of  the  organ,  but  its  connection  with  the  underlying 
muscular  tissue  is  probably  as  intimate  as  in  the  non-pregnant  condition. 

The  very  great  hypertrophy  of  the  mucous  membrane  has  been  stated, 
and  the  early  history  of  the  deciduous  membranes  traced.  By  the  end 
of  the  third  month  of  pregnancy  the  decidua  of  the  ovum,  ovular  decidua, 
decidua  reflexa,  and  the  uterine  decidua,  decidua  vera,  are  in  contact. 
In  the  course  of  the  fourth  month  the  two  layers  coalesce,  making  a 
single  membrane,  which  in  turn  is  closely  united  with  the  chorion,  the 
external  covering  developed  by  the  ovum,  and  thus  the  ovum  has  not 
only  the  closely  united  chorion  and  amnion,  but  also  external  to  these 
the  decidua.  The  mucous  membrane  of  the  uterus  in  pregnancy  has  no 
longer  ciliated,  but  pavement-epithelium. 

The  decidua,  formed  by  the  conjoined  ovular  and  uterine  decidua, 
atrophies,  grows  thinner,  and  in  preparation  for  being  thrown  off  with 
the  ovum  gradually  becomes  detached  from  the  uterus.  But  the  mus- 


CHANGES  IN  THE  MATERNAL  ORGANISM. 


173 


cular  tissue  is  not  left  bare  by  this  detachment.  Some  physiologists, 
among  them  Robin,  asserted  that  a  new  mucous  membrane  begins 
forming  behind  the  decidua  at  four  months ;  Dr.  Matthews  Duncan's 
criticism  upon  this  view  is  that  it  implies  at  some  time  the  muscular 
tissue  was  left  bare,  aud  that  it  produces  upon  its  surface  a  mucous 
tissue  heterologous  to  it.  According  to  Friedlander,  the  decidua  is  at 
the  end  of  pregnancy  reduced  to  two  layers,  superficial  and  deep ;  the 
latter  is  composed  of  glandular  culs-de-sac  and  connective  tissue,  aud  the 
former  of  cells  in  fatty  degeneration,  and  this  only  is  thrown  off. 
Engelmann  also  states  that  only  the  superficial  part  of  the  decidua  vera 
is  discharged.  Ercolaui1  taught  that  the  uterine  decidua  was  a  product 
of  materials  elaborated  by  the  utricular  glands,  and  that  the  ovum, 
arriving  in  the  uterus  already  covered  by  this  decidua,  soon  itself 
receives  a  similar  investment,  this  covering  fixing  it  at  a  particular  part 
of  the  uterus.  The  deciduous  membranes  were  regarded  by  him  as 
exudations,  new  formations.  His  views  have  not  met  professional 
acceptance. 

FIG.  97. 


d 


SECTION  THROUGH  THE  DECIDUA.    (FRIEDLANDER.) 

a.  Amnion.    b.  Chorion.    c.  Decidua.    d.  Uterine  muscle,    e.  Line  of  separation  in  the 
cellular  layer.   /.  Cellular  layer,    g.  Glandular  layer. 

MODIFICATIONS  OF  ARTERIES  AND  VEINS  OF  THE  UTERUS.  The 
arteries  of  the  uterus  increase  in  length,  in  volume,  and  in  number. 
Jacquemier  has  stated  that  their  increase  in  length  cannot  be  attributed 
to  their  becoming  less  flexuous,  for  they  are  more  flexuous  at  the 
end  of  gestation  than  they  are  in  the  non-pregnant  uterus.  The  ovarian 
arteries  acquire  a  diameter  of  nearly  one-sixth  of  aa  inch,  four  and  a 
half  millimetres,  and  the  uterine  arteries  are  still  larger ;  the  branch  on 
each  side  connecting  the  uterine  and  the  ovarian  arteries  is  larger  than 
the  radial ;  its  course  is  nearly  parallel  with  the  epigastric,  and  it  has 
received  from  Glenard,2  who  thought  it  the  seat  of  the  uterine  souffle, 
the  name  of  puerperal  artery.  Arteries  upon  entering  the  uterus  sud- 

1  Utricular  Glands  of  the  Uterus.    Translated  from  the  Italian  by  Dr.  H.  D.  Marcy. 

2  This  theory  of  the  uterine  souffle  has  been  proved  erroneous. 


174  PHYSIOLOGY  OF  PREGNANCY. 

denly  enlarge ;  branches  of  the  one  side  anastomose  freely  with  each 
other  and  with  those  from  the  other  side ;  they  are  situated  nearer  to 
the  peritoneal  than  to  the  mucous  coat,  except  in  the  vicinity  of  the 
placenta ;  those  which  pass  to  the  mucous  coat  make  numerous  sub- 
divisions, and  end  in  an  extensive  capillary  network.  The  venous 
system  in  the  muscular  coat  is  composed  of  a  large  number  of  sinuses  or 
large  canals  which  communicate  with  each  other ;  some  of  the  vessels 
are  as  large  as  the  little  finger.  They  are  without  valves,  and  in  the 
middle  muscular  layer  are  reduced  to  a  single  coat,  which,  however,  is 
closely  adherent  to  the  surrounding  muscular  fibres.  They  are  more 
numerous  in  the  vicinity  of  the  placenta.  The  ovarian  veins  become 
almost  equal  in  size  to  the  external  or  internal  iliac. 

CHANGES  IN  THE  SIZE,  CAPACITY,  AND  FORM  OF  THE  UTERUS. 
Increase  of  the  constituents  of  the  uterus  is  associated  with  remarkable 
development  of  the  organ  in  size  and  capacity.  The  uterus  undergoes 
very  great  eccentric  hypertrophy,  so  that  at  the  end  of  pregnancy  it 
measures,  according  to  Spiegel  berg,  about  twelve  inches  and  three- 
quarters,  35  centimetres,  in  length,  about  nine  inches  and  a  half,  24 
centimetres,  in  breadth,  and  autero-posteriorly  nine  inches,  or  23  centi- 
metres. The  late  Sir  James  Simpson  gave  the  following  measurements 
of  the  uterus  :  length  twelve  to  fifteen  inches,  breadth  nine  to  ten  inches, 
the  antero-posterior  measurement  six  to  eight  inches.  He  further  stated 
the  surface  of  the  unimpregnated  uterus  is  five  or  six  square  inches,  and 
its  capacity  one  cubic  inch  ;  but  at  the  end  of  pregnancy  the  surface  of 
the  organ  is  three  hundred  and  fifty  square  inches,  and  its  capacity  four 
hundred  cubic  inches.  Tarnier  regards  the  last  measurement  as  somewhat 
exaggerated;  Krause  states  the  capacity  is  increased  519.  The  weight 
of  the  uterus  is  twenty  to  twenty-four  times  greater  than  in  the  virgin 
state.  Spiegelberg  attributed  the  greater  size  of  the  uterus  partly  to 
the  organ  being  stretched  by  the  ovum,  claiming  that  the  thickness  of 
the  walls,  which  increases  during  the  first  months,  diminishes  in  the 
latter  months  so  that  it  is  less  than  before  impregnation.  Velpeau  and 
Depaul  both  held  that  pregnancy  caused  no  great  change  in  the  thickness 
of  the  walls,  a  view  sustained  by  Charpentier ;  the  uterine  walls  are 
thinner  at  the  inferior  segment,  thicker  in  the  fund  us  and  body,  espe- 
cially at  that  part  to  which  the  placenta  is  attached,  according  to  Naegele 
and  Grenser.  Tarnier  holds  that  the  thickness  generally  lessens  toward 
the  end  of  pregnancy,  but  is  quite  variable  in  different  subjects,  and  is 
very  unequal  in  different  parts.  It  is  impossible,  therefore,  to  fix  a 
uniform  measure  for  the  thickness  of  the  walls  of  the  pregnant  uterus. 

The  uterus  has  different  forms  in  the  successive  periods  of  pregnancy. 
During  the  first  three  months  it  becomes  pyriform  instead  of  triangular. 
After  three  months  it  gradually  takes  the  form  of  a  flattened  spheroid, 
and  it  is  only  in  the  latter  part  of  pregnancy  that  it  becomes  ovoidal, 
the  smaller  end  of  the  ovoid  being  below.  Nevertheless,  as  remarked 
by  Spiegelberg,  the  uterus  is  not  to  be  regarded,  especially  in  the  latter 
months,  as  a  rigid  body  with  a  constant  form,  for  many  deviations 
occur,  the  shape  depending  upon  the  woman's  position,  the  volume  of 
the  ovum,  the  situation  of  the  foetus,  the  tension  of  the  organ,  and  also 
upon  its  primitive  formation. 


CHANGES  IN  THE  MATERNAL  ORGANISM.  175 

CHANGES  IN  THE  POSITION  OF  THE  UTERUS  AND  IN  THE  CONSIST- 
ENCE OF  THE  UTERINE  WALLS.  Modifications  in  the  weight  and  in 
the  size  of  the  uterus  necessarily  cause  changes  in  its  position.  It  is 
generally  taught  that  in  the  first  weeks  of  gestation  the  uterus  is  lower 
in  the  pelvis ;  and  indeed  a  flattening  of  the  hypogastrium  caused  by 
this  descent  'is  regarded  as  one  of  the  earliest  signs  of  pregnancy. 
Tarnier  thinks  this  change  far  from  constant ;  in  a  great  number  of 
women  the  fund  us  of  the  uterus  from  the  first  weeks  of  pregnancy 
passes  the  superior  pubic  margin,  and  the  neck  does  not  descend. 
However  this  may  be,  at  three  months  the  fundus  is  a  finger's  breadth 
or  more  above  the  pubes ;  at  the  end  of  the  fourth  month  it  is  two 
inches  or  more,  five  to  six  centimetres,  above  ;  at  five  months  3.5  to  3.9 
inches,  nine  to  ten  centimetres,  above ;  the  distance  of  the  fundus  above 
the  pubes  increases,  becoming  greatest  in  the  first  half  of  the  ninth 
month,  when  it  amounts  to  8.6  to  9.4  inches,  22  to  24  centimetres.  In 
the  last  two  weeks  there  is  usually  a  marked  descent,  arising  from  the 
entrance  of  the  fetal  head,  still,  however,  inclosed  in  the  uterus,  into 
the  pelvic  cavity.  It  should  be  remembered  that  in  the  multigravida 
previous  relaxation  of  the  abdominal  wall  permits  the  uterus  to  project 
further  in  front,  and  does  not  compel  the  fundus  to  ascend  as  high  as 
does  the  tense  abdominal  wall  of  the  primigravida.  Further,  in  the 
latter  the  descent  of  the  presenting  part  into  the  pelvic  cavity  occurs 
earlier.  While  the  chief  factor  in  producing  this  descent  is  the  resist- 
ance of  the  abdominal  wall  to  further  encroachment  of  the  growing 
uterus,  yet  another  factor  is  the  uterus  itself,  which  in  the  primigravida 
is  more  rigid,  and,  according  to  Martel,1  this  rigidity  maintains  the  axis 
of  the  foetal  ovoid  in  correspondence  with  the  axis  of  the  uterus,  hence 
there  is  a  tendency  to  force  the  lower  part  of  the  uterine  ovoid  into  the 
pelvic  cavity. 

The  uterus  after  ascending  into  the  abdominal  cavity  in  very  few 
cases  occupies  a  median  position,  for  its  posterior  convex  wall  is  not 
adapted  to  the  convexity  of  the  spine,  and  the  organ  therefore  turns  to 
one  or  the  other  side — to  the  right  side  in  the  great  majority  of  women. 
This  obliquity  of  the  uterus,  probably  having  its  cause  in  a  condition 
of  embryonic  development,  should  be  borne  in  mind  in  case  gastro- 
hysterotomy  is  to  be  done.  So;  too,  the  normal  latero-version  may  in 
labor  retard  the  descent  of  the  foetal  head,  and  require  to  be  corrected 
by  changing  the  position  of  the  woman.  But  iu  addition  to  the  usual 
right  obliquity,  there  is  also  a  partial  rotation  of  the  uterus  by  which 
the  left  side  of  the  organ  is  thrown  forward,  and  the  right  backward,  a 
change  very  plainly  dependent  upon  its  embryonic  development,  as  has 
been  previously  mentioned.  This  change  of  position  causes  the  left 
side  of  the  uterus  to  be  more  accessible  in  auscultation  made  for  the 
purpose  of  hearing  the  uterine  souffle. 

The  consistence  of  the  uterine  wall  is  greatly  changed.  Instead  of 
being  rigid  and  resisting  as  in  the  unimpregnanted  uterus,  it  becomes 
yielding  to  localized  pressure  from  within  or  from  without ;  but  it  is  also 
elastic,  so  that  as  soon  as  the  pressure  is  removed  there  is  complete  res- 

1  De  1'Accommodation  en  Obstetrique. 


176  PHYSIOLOGY  OF  PREGNANCY. 

toration  of  form.  As  Pajot  observes,  this  suppleness  and  special  elas- 
ticity of  the  uterus  are  neither  softness  nor  a  flaccid  condition ;  it  is  always 
possible  to  distinguish  the  uterus  from  the  abdominal  walls,  and,  on  the 
other  hand,  the  suppleness  and  elasticity  contribute  to  maintain  the 
normal  accommodation  of  the  fetus,  and  thus  avoid  unfavorable  pre- 
sentations and  positions  without  interfering  with  its  active  movements. 

RELATIONS  OF  THE  UTERUS  AT  THE  END  OF  PREGNANCY.  The 
lower  fourth  of  the  anterior  uterine  wall  is  in  relation  with  the  posterior 
wall  of  the  bladder ;  the  remaining  three-fourths  is  directly  applied  to 
the  abdominal  wall,  but  sometimes  omentum  or  intestine  may  intervene. 
The  fundus  is  in  relation  with  the  transverse  colon,  part  of  the  stomach, 
with  the  anterior  margin  of  the  liver,  the  xiphoid  cartilage,  and  the 
lower  floating  ribs.  The  ovaries  and  oviducts  are  close  to  the  sides  of 
the  uterus  at  a  point  corresponding  with  the  junction  of  the  upper  and 
middle  third  ;  this  change  in  their  position  shows  the  remarkable 
development  of  the  fundus  of  the  uterus.  Further,  the  right  side  of  the 
uterus  is  in  relation  with  the  internal  and  external  iliac  vessels,  with  the 
obturator  nerves,  the  psoas  and  iliac  muscles,  the  caecum  and  the 
ascending  colon  ;  the  left  side  has  similar  relations  to  bloodvessels, 
nerves,  and  muscles,  and  with  the  descending  colon,  instead  of  with  the 
ca3cum  and  ascending  colon.  The  posterior  wall  is  in  relation  with  the 
rectum,  the  sacrum,  the  primitive  iliacs,  the  sacro-vertebral  angle,  the 
omeutum,  the  small  intestine,  the  aorta,  the  vena  cava,  the  dorsal  and 
lumbar  vertebrae,  and  the  pillars  and  the  posterior  part  of  the  dia- 
phragm. 

PROPERTIES  OF  THE  PREGNANT  UTERUS  :  SENSIBILITY,  IRRITA- 
BILITY, CONTRACTILITY,  RETRACTILITY.  Pajot  has  said,  pregnancy 
does  not  create  any  new  property.  But  the  properties  which  the 
uterus  already  possesses  are  increased ;  for  example,  the  organ  is  more 
sensitive  and  its  nerves  respond  more  readily  to  stimuli,  or,  in  other 
words,  its  sensibility  and  irritability  are  greater.  From  its  vast  in- 
crease in  size  it  is  more  exposed  to  the  action  of  causes  that  affect  these 
properties.  The  sensibility  of  the  uterus  varies  in  different  subjects, 
and  hence  in  some  all  active  foetal  movements  cause  severe  suffering, 
while  others  experience  only  a  momentary  inconvenience  from  such 
movements.  The  suffering  caused  by  foetal  movements  is  often  dif- 
ferent in  different  parts  of  the  uterus,  in  one  severe,  in  another  slight ; 
the  frequent  repetition  of  movements  referred  to  one  portion  of  the 
uterus  will  there  cause,  in  some  cases,  increasing  distress.  So,  too,  the 
irritability  of  the  uterus  is  not  the  same  in  all ;  trivial  causes  in  one 
woman  will,  from  the  great  irritability  of  the  uterus,  excite  contrac- 
tions and  lead  to  abortion,  while  another  is  subjected  to  the  severest 
violence  without  interruption  of  pregnancy.  Idiosyncrasy  is  supposed 
to  explain  cases  of  excessive  sensibility,  or  of  excessive  irritability  of 
the  uterus ;  but  in  some  instances  at  least  the  explanation  is  to  be 
sought,  not  in  a  peculiar  physiological,  but  in  a  positive  pathological 
condition. 

Consequent  upon  irritability  is  contractility,  contraction  is  the  re- 
sponse to  irritation  ;  contractility  is  manifested  by  shortening  of  mus- 
cular fibre  followed  by  lengthening.  The  physiological  irritability  of 


CHANGES  IN  THE  MATERNAL  ORGANISM. 

FIG.  98. 


177 


POSITION  OF  THE  GRAVID  UTERUS  NEAR  TERM,  AND  SOME  OF  THE  RELATIONS  OF  THE  INTESTINES. 

a.  Gravid  uterus,    d.  Ascending  colon,    e.  Kidney.   /,/.  Small  intestine,    h.  Transverse 

colon,    i.  Liver.    I.  Diaphragm. 

12 


178  PHYSIOLOG  Y  OF  PREGNANCY. 

the  uterus  is  manifested  by  the  occurrence  of  contractions,  which  become 
more  frequent  as  the  pregnancy  approaches  its  end ;  these  contractions 
are  painless,  but  as  they  gradually  merge  into  the  contractions  of  labor 
they  become  more  frequent  and  are  accompanied  with  suffering.  Con- 
tractility is  a  property  of  all  the  muscular  tissue  of  the  uterus,  but  of 
course  is  greatest  in  those  parts  of  the  organ  where  this  tissue  is  most 
developed.  The  painless  contractions  of  pregnancy  promote  the  circu- 
lation of  the  blood  in  the  uterine  sinuses,  and  also  assist  in  fixing  the 
foetal  presentation.  The  manifestation  of  contractility  in  labor  will  be 
elsewhere  considered. 

Retractility  of  the  uterus  has  been  defined  as  a  property  of  the  mus- 
cular tissue,  by  virtue  of  which  the  uterine  walls  tend  to  approach.  It 
opposes  distention,  and  is  the  antagonist  of  the  elasticity  which  permits 
for  the  moment  stretching  of  a  part  of  the  uterine  walls.  While  con- 
tractility is  a  force  manifested  intermittently,  retractility  is  constant  in 
its  action  and  permanent.  It  restores  the  form  of  the  uterus,  tem- 
porarily lost  by  foetal  movements  or  by  changes  of  the  mother's  posi- 
tion ;  it  keeps  the  uterine  walls  closely  applied  to  the  ovum,  and  after  the 
detachment  of  the  placenta  it  closes  bleeding  vessels,  while  during  the 
puerperal  state  it  prevents  distention  of  the  uterine  cavity  by  blood- 
clots,  and  is  one  of  the  most  important  agents  in  promoting  uterine 
involution.  Contraction  and  retraction  are  two  distinct  nodalities  of 
muscular  action ;  neither  is  a  condition,  but  each  is  a  manifestation  of 
muscular  force. 

CHANGES  IN  THE  NECK  OF  THE  WOMB.  Slight  hypertrophy  of 
the  neck  of  the  womb  occurs  in  pregnancy  ;  this  part  of  the  uterus  is 
not  so  well  supplied  with  blood  as  the  body  is,  and  is  not  subjected 
to  the  irritation  from  the  growing  ovum,  at  least  until  the  latter  weeks 
of  pregnancy,  and  then  the  pressure  of  the  ovum  is  chiefly  at  its  upper 
portion,  and  hence  its  little  increase  in  size. 

The  position  of  the  neck  depends  upon  the  position  of  the  womb,  and 
therefore,  as  the  latter  ascends  into  the  abdominal  cavity,  the  neck  is 
drawn  up  and  apparently  shortened.  Anterior  inclination  of  the  uterus 
causes  the  cervix,  unless  there  be  marked  anteflexion,  to  point  backward 
to  the  hollow  of  the  sacrum ;  lateral  inclination  directs  the  neck  toward 
that  side  of  the  pelvis  opposite  to  the  side  of  the  abdominal  cav:ty  in 
which  the  fundus  is ;  in  primigravidaj  the  os  uteri  is  usually  found  at 
the  end  of  pregnancy  quite  far  posteriorly  and  to  the  left  of  the  pelvic 
cavity.  In  primigravidse  the  virgin  form  of  the  neck  is  more  distinct 
— that  is,  more  plainly  conical ;  but  after  a  time,  in  consequence  of  the 
accumulation  of  the  secretion  of  its  glands  in  its  canal,  it  is  spindle- 
shaped.  In  the  multigravidae  it  is  cylindrical  or  expanded  at  its  lower 
portion  so  as  to  be  club-shaped. 

SOFTENING  OF  THE  NECK.  Early  in  pregnancy  a  change  in  the 
consistence  of  that  part  of  the  neck  adjoining  the  external  os  begins,  and 
is  manifested  by  the  superficial  tissues  yielding  to  pressure.  This  soft- 
ening is  at  first  simply  a  continuation  of  that  caused  by  the  last  menstrua- 
tion ;  the  softening  advances  regularly  and  slowly  in  the  primigravida 
to  the  remaining  portion  of  the  vaginal  cervix,  so  that,  approximately, 
one-fourth  is  affected  by  it  at  four  months,  one-half  at  six,  three-fourths 


CHANGES  IN  THE  MATERNAL  ORGANISM. 


179 


at  seven,  and  the  remaining  fourth  at  eight  mouths.  In  the  multigra- 
vida  the  process  is  more  rapid,  because  the  neck  is  shorter  and  has  been 
previously,  softened.  The  softening  always  begins  below,  thence  passing 
above.  It  is  attributed  to  a  greater  abundance  of  plasma,  to  hypertrophy 
and  proliferation  of  fibre-cells,  and,  in  the  latter  part  of  pregnancy,  to 
blood-stasis  caused  by  the  pressure  of  the  foetal  head  in  the  lower  por- 
tion of  the  uterus.  The  sensation  that  the  finger  receives  by  pressing 
upon  the  softened  cervix  has  been  compared  to  that  which  is  given  by 
similar  pressure  upon  a  piece  of  velvet  placed  upon  a  hard  substance,  at 
first  a  ready  yielding  to  the  pressure,  and  then  a  firm  resistance.  Soft- 
ening of  the  neck  is  in  the  early  months  of  pregnancy  a  valuable  sign, 
which  may  assist  in  a  probable  diagnosis  of  the  pregnant  state. 

STATE  or  THE  INTERNAL  AND  THE  EXTERNAL  Os.  In  primigra- 
vidse  the  external  orifice  of  the  womb  remains  closed  until  the  end  of 
pregnancy.  In  rare  instances  the  finger  can  enter  it,  but  usually  for 
only  a  short  distance,  and  in  some  of  these  possibly  the  penetration  has 
been,  not  by  an  open  canal,  but  from  making  it  permeable  by  pressure. 
In  still  rarer  instances  the  cervical  canal  in  primigravidae  is  permeable 
by  the  finger  in  the  latter  weeks  of  pregnancy,  so  that  the  fetal  mem- 
branes and  presenting  part  may  be  touched  ;  such  cases  are  quite  excep- 
tional. In  multigravidae  the  external  os  is  not  surrounded  by  a  regular 
smooth  surface,  but  by  a  structure  marked  with  irregular  fissures ;  the 
cervical  canal  is  open  to  a  degree  in  direct  relation  with  the  period  of 
pregnancy,  the  finger  readily  passing,  for  example,  to  the  middle  of  the 
canal  at  seven  months;  the  cavity  thus  entered  by  the  finger  is  funnel- 
shaped,  or  the  neck  of  the  womb  may  be  represented  as  a  hollow  cone, 
with  its  base  below. 


FIG.  99. 


PIG.  100. 


SCHEMATIC  SECTION  OF  A  PRIMIPARA  IN 
THE  LAST  MONTH.    (SCHROEDER.) 


SCHEMATIC  SECTION  OF  A  MULTIPARA  IN 
THE  LAST  MONTH.    (SCHROEDER.) 


1 80  PHYSIOLOG  Y  OF  PREGNANCY. 

SHORTENING  OF  THE  NECK  OF  THE  WOMB.  The  question  as  to 
shortening  of  the  cervix  became  the  subject  of  controversy  nearly  two 
centuries  ago,  and  in  quite  recent  years  the  contention  has  been  greater 
than  at  any  previous  time.  De  Graaf,  1671,  held  that  the  cervix  re- 
mained unchanged  until  the  end  of  pregnancy,  and  the  same  view  was 
maintained  by  Verhegen,  1710,  and  Weitprecht,  1750.  Roederer, 
1753,  asserted  that  expansion  of  the  cervical  canal,  contributing  thus 
to  the  uterine  cavity,  advanced  regularly  from  above  downward  during 
pregnancy,  stating  that  this  change  could  be  noticed  as  early  as  toward 
the  sixth  month.1  Stoltz,  1826,  stated  that  the  cervix  was  unchanged 
until  the  last  fifteen  days  of  pregnancy,  and  then  the  internal  os 
opens,  the  cervical  canal  dilates  from  above  downward,  and  the  cervix 
is  gradually  effaced.  Taylor,  1862,  brought  forward  important  obser- 
vations to  prove  that  the  cervix  did  not  shorten  until  the  beginning  of 
labor.  In  1876  Bap.dl  revived  the  teaching  of  Roederer,  asserting  that 
during  the  last  ten  weeks  of  pregnancy  shortening  of  the  cervix  is  in 
progress ;  the  upper  part  of  the  cervical  canal  is  dilated  so  as  to  form 
with  the  lower  segment  of  the  uterus  the  canal  of  Braun,  or,  as  Tarnier 
calls  it,  the  cervico-uterine  canal.  Bandl  contended  that  the  superior 
limit  of  the  cervical  canal,  or  the  internal  os  uteri,  could  be  demonstrated 
at  the  close  of  pregnancy  or  during  labor  to  be  at  the  level  of  the  pelvic 
inlet. 

While  some  have  thus  held  that  the  lower  uterine  segment  was  cervical  in 
origin,2  others  partly  from  the  cervix  and  partly  from  the  body  of  the  uterus,  the 
view  now  most  generally  accepted  is,  as  expressed  by  Barbour,3  "  that  no  suffi- 
cient evidence  has  been  produced  that  the  lower  segment,  which  resembles  in  its 
essential  structure  the  rest  of  the  uterus,  is  cervical  in  its  origin ;  and  until  new 
evidence  is  brought  forward  we  see  no  reason  to  ascribe  to  it  an  origin  different 
from  the  rest  of  the  wall  of  the  uterus." 

It  would  seem,  however,  that  after  efFacement  of  the  cervix  at  the  end  of  preg- 
nancy and  the  beginning  of  labor  the  cervical  tissue  must  contribute  to  the  lower 
portion  of  the  completed  uterine  ovoid,  which  then  presents  a  simple  nearly  cir- 
cular opening  and  no  canal. 

Bibemont-Dessaignes  and  Le  Page,  op.  cit.,  assert  that  the  neck  keeps  its  entire 
length  during  pregnancy,  to  the  beginning  of  labor,  and  that  the  lower  segment 
of  the  uterus  to  the  end  of  pregnancy  is  formed  not  by  the  neck  but  by  the  in- 
ferior part  of  the  body  of  this  organ. 

In  regard  to  the  changes  of  the  cervix  in  pregnancy,  Spiegelberg 
observed,  it  is  no  longer  doubtful  that  the  opening  of  the  internal  os 
uteri  and  the  entering  of  the  apex  of  the  ovum  into  the  cervical  canal, 
thus  causing  this  canal  to  contribute  to  the  uterine  cavity,  are  possible 
phenomena,  and  in  fact  do  occur.  Their  occurrence  is  thus  explained  : 
In  primigravidae  the  lower  portion  of  the  uterus  does  not  readily  yield 
to  the  pressure  of  the  growing  ovum  and  to  the  uterine  contractions, 
which  become  more  frequent  in  the  latter  part  of  pregnancy,  and  hence 
the  development  of  the  cervical  canal  is  more  frequent  in  them,  but  the 

1  Although  Kleinwachter  refers  impliedly  to  Roederer's  views  as  indicating  that  the  changes 
occurred  in  the  last  teu  weeks  of  pregnancy,  yet  upon  referring  to  Wrisberg's  edition  of  Roederer's 
Elementa  Artis  Obstetricise,  1766,  the  time  is  stated  to  be  versus  sexlem  mensem. 

2  According  to  this  view,  Bandl's  ring  is  the  dilated  internal  os  uteri,  the  upper  limit  of  the 
inferior  segment,  and  Miiller's  ring  is  that  which  appears  to  be  the  internal  os,  the  upper  limit  of 
the  shortened  cervical  canal. 

3  The  Anatomy  of  Labor.    Edinburgh.  1889. 


CHANGES  IN  THE  MATERNAL  ORGANISM. 


181 


external  os  remains  closed,  or  nearly  so,  until  the  end  of  pregnancy. 
On  the  other  hand,  in  multigravidse  the  lower  portion  of  the  uterus  is 
less  resisting,  yields  readily  to  the  growing  ovum,  and  therefore  the 
internal  os  remains  closed,  not  being  subjected  to  so  much  pressure 
either  from  the  ovum  or  from  uterine  contractions,  and  the  finger  can 
in  these  cases  be  passed  further  and  further  up  the  cervical  canal  with 
the  progress  of  the  pregnancy,  the  development  of  the  canal  being  from 
below  above. 

Fig.  101  shows  no  shortening  of  the  neck,  but  in  the  last  two  weeks 
of  pregnancy,  according  to  Stolz,  Tarnier,  and  others,  such  shortening 


FIG.  101. 


CERVIX  OF  A  WOMAN  DYING  IN  THE  EIGHTH  MONTH  OF  PREGNANCY.    (After  DUNCAN.) 

occurs  in  most  cases ;  it  is  admitted,  however,  that  this  change  may  not 
occur  until  a  few  days,  or  even  a  few  hours  before  labor  begins.  Tay- 
lor has  more  recently  repeated  his  statement1  as  to  the  non-shortening 
of  the  cervix  in  pregnancy,  and  sustained  it  by  additional  facts  and 
arguments. 

Barbour's*  conclusion  from  a  study  of  "  frozen  sections"  of  women 
dying  in  pregnancy  is  that  the  cervical  canal,  lined  by  characteristic 
mucous  membrane,  remains  of  "  pretty  constant  length."  This  view 
is  that  which  is  generally  accepted. 

When  the  neck  has  disappeared,  been  effaced3  by  being  taken  up  into 
the  body  of  the  womb,  the  uterine  changes  of  pregnancy  are  completed, 
and  labor  is  at  hand. 

1  Transactions  Medical  Society  of  New  York,  1888.  *  Op.  cit. 

3  Charpentier,  by  a  strange  confusion  of  language,  as  it  seems  to  me,  refers  to  the  effacement  of 
the  neck  as  a  phenomenon  of  pregnancy,  but  dilatation  of  the  neck  as  a  phenomenon  of  labor. 
But  how,  after  it  is  effaced,  can  it  be  dilated  ?  Dilatation  of  the  os,  but  not  of  the  neck,  is  a  phe- 
nomenon of  labor. 


182  PHYSIOLOGY  OF  PREGNANCY. 

CHANGES  IN  THE  UTERINE  APPENDAGES.  The  broad  ligaments 
have  their  peritoneal  layers  separated  by  the  growing  uterus,  and  as  the 
organ  ascends  they  are  carried  up  by  it;  they  share  in  the  hypertrophy 
of  the  peritoneum  covering  the  uterus.  The  ascension  of  the  uterus 
compels  a  change  in  their  direction,  so  that  at  the  end  of  pregnancy 
they  are  vertical  instead  of  horizontal. 

The  round  ligaments  have  their  thickness  increased  fourfold ;  they 
become  much  longer,  and  at  the  termination  of  gestation  extend  from 
the  vicinity  of  the  umbilicus  to  the  inguinal  canal  on  each  side;  in 
consequence  of  the  greater  development  of  the  posterior  than  of  the 
anterior  wall  of  the  uterus,  they  are  not  directly  upon  the  sides,  but  at 
the  junction  of  the  posterior  four-fifths  with  the  anterior  fifth  of  the 
lateral  borders  of  the  uterus.  The  utero-sacral  ligaments,  the  uterine 
retractors  of  Luschka,  undergo  remarkable  development.  The  ovaries 
increase  in  size ;  according  to  Jacquemier,  their  size  is  doubled ;  they 
follow  the  movements  of  the  broad  ligament,  and  take  nearly  a  vertical 
position.  Ovulation  in  most  cases,  at  least,  is  suspended,  but  the  corpus 
luteum  undergoes  the  changes  which  have  been  described  as  occurring 
in  pregnancy.  The  oviducts  also  hypertrophy ;  their  epithelial  lining 
loses  its  vibratile  cilia.  Robin  has  stated  that  the  canal  of  the  oviduct 
contains  a  yellowish-white  viscous  matter,  holding  in  suspension  epi- 
thelial nuclei  and  fine  fat  granulations. 

CHANGES  IN  THE  BREASTS.  In  some  cases  the  mammary  glands 
become  larger  at  the  beginning  of  pregnancy,  but  oftener  this  increase 
in  size  commences  at  the  time  corresponding  with  the  first  menstrual 
suppression  following  conception.  Their  enlargement  is  accompanied 
with  increased  sensibility,  and  occasional  shooting  pains  are  felt  in  them ; 
the  axillary  ganglia  may  also  be  similarly  affected.  The  superficial 
veins  are  larger  and  more  distinct ;  if  the  increase  in  size  of  the  breasts 
be  very  great,  it  is  not  unusual  for  strise  similar  to  those  occurring  upon 
the  abdominal  wall  to  be  found  about  the  fifth  or  sixth  month.  In 
some  cases  the  enlargement  lessens  after  four  or  five  months,  but  re- 
appears toward  the  end  of  pregnancy.  The  latter  part  of  the  second 
or  third  month  the  nipple  is  firmer,  harder,  more  prominent,  and  sensi- 
tive; a  milk-like  fluid  may  possibly  escape  or  be  pressed  from  it,  but 
this  is  not  usually  observed  until  in  the  last  three  months,  and  it  may 
happen  even  in  the  absence  of  pregnancy. 

Changes  in  the  areola  are  more  important  and  characteristic.  These 
changes  are  swelling,  development  of  the  mamillary  tubercles,  and 
darkening  of  the  entire  surface.  The  first  of  these  phenomena  can 
usually  be  seen  the  second  month ;  the  swelling  is  not  hard  and  tense, 
but  puffy,  giving  to  the  finger  the  sensation  of  an  emphysematous 
enlarged  tissue.  About  the  same  time  the  areola  becomes  darker,  and 
the  hue  deepens  until  the  end  of  pregnancy,  when  in  brunettes  it  is  a 
dark  brown,  in  some  almost  black,  while  in  blondes  this  change  is 
much  less  pronounced,  and  in  the  red-haired  scarcely  noticeable.  The 
papular  elevations,  often  called  the  tubercles  of  Montgomery,  situated 
upon  the  areola,  and  regarded  by  some  as  miniature  mammary  glands, 
become  much  more  prominent,  projecting  from  the  sixteenth  to  the 
eighth  of  an  inch.  The  primary  areola,  which  has  a  radius  of  about 


CHANGES  IN  THE  MATERNAL  ORGANISM. 


183 


an  inch,  three  centimetres,  is  surrounded  at  the  fifth  or  sixth  month  by 
a  secondary  areola  ;  this  is  lighter  in  color,  and  necked  with  whitish 
spots,  presenting  an  appearance  somewhat  resembling  that  of  dust- 


FIG.  102. 


THE  PRIMARY  AND  SECONDARY  AREOLA  IN  PREGNANCY. 

covered,  white  blotting-paper  upon  which  drops  of  water  have  been 
sprinkled.  The  illustration  (Fig.  102),  from  Depaul,  very  well  repre- 
sents the  appearance  of  the  breast  in  the  latter  months  of  pregnancy. 


CHAPTER    VII. 

THE   SIGNS   ANJ>   DIAGNOSIS   OF    PREGNANCY. 

PREGNANCY  is  revealed  by  certain  signs,  and  its  diagnosis  is  made 
by  their  recognition  and  application.  It  is  essential  that  the  obstetric 
student  faithfully  study  and  clearly  understand  these  signs,  and  then, 
by  giving  to  each  its  true  value  and  combining  all,  he  will  reach  a 
correct  conclusion.  Van  Swieten  said  that  the  physician's  reputation 
was  never  more  imperilled  than  in  deciding  as  to  pregnancy  :  "  frauds 
everywhere,  often  everywhere  snares  prepared  for  the  unwary."  But 
not  only  may  a  mistake  in  diagnosis  be  very  injurious  to  his  reputa- 
tion, it  may  ruin  the  reputation  of  one  unjustly  accused  of  being  preg- 
nant, or  risk  the  health,  or  even  the  life  of  another  affected  by  a  disease 
simulating  pregnancy  ;  and  this  disease,  thus  neglected,  may  become 
incurable.  That  great  mistakes  have  been  made  in  the  diagnosis  of 
pregnancy — this  condition  asserted  when  it  was  absent,  or  denied  when 
it  was  present — and  that  these  mistakes  have  in  some  instances  led  to 
most  deplorable  consequences,  is  matter  both  of  printed  and  oral  history. 
Few  practitioners  of  a  dozen  years'  experience  can  truthfully  say  that 
no  error  in  the  diagnosis  of  pregnancy  has  ever  been  made  by  them. 
Pajot  states  that  he  could  make  quite  a  volume  giving  in  detail  the 
history  of  all  the  erroneous  diagnoses  in  regard  to  pregnancy  which  have 
come  under  his  own  observation  in  an  experience  of  thirty  years  ;  and 
these  mistakes  made,  not  by  sages  femmes,  but  by  practitioners  of  more 
or  less,  some  of  them  with  very  long,  experience. 

Now,  there  must  be  reasons  for  such  great  and  comparatively  fre- 
quent mistakes,  and  a  brief  exposition  of  some  of  these  causes  of  error 
may  help  to  avert  the  latter.  Socrates  said  :  "  To  attain  to  a  knowledge 
of  ourselves  we  must  banish  prejudice,  passion,  and  sloth."  These, 
too,  must  be  banished  when  we  study  the  practical  diagnosis  of  preg- 
nancy. Especially  must  we  investigate  a  case  without  prejudice — that 
is,  without  prejudgment — whether  the  prejudice  be  from  the  opinion 
of  others,  or  from  the  subject's  previous  history  and  her  surroundings. 
That  the  judgment  of  another  is  in  favor  of  or  adverse  to  pregnancy 
must  not  rule  our  own ;  nor  should  our  opinion  be  biased  by  the  social 
position,  reputation,  and  circumstances  of  the  party ;  for  some  women, 
around  whom  apparently  every  safeguard  has  been  thrown,  may  sacrifice 
their  virtue,  while  others,  less  protected,  preserve  it  in  the  midst  of  the 
strongest  temptations.  In  this  judicial  inquiry  the  woman  must  be 
divested  of  all  the  accidents  of  life,  of  all  her  artificial  surroundings, 
and  simply  considered  as  capable  of  reproduction.  Her  statements  are 
to  be  received  with  great  caution,  for,  on  the  one  hand,  a  strong  imagi- 
nation will  beget  in  her,  if  she  ardently  desires  to  be  a  mother,  some  of 
the  signs  of  pregnancy  ;  or,  if,  she  wishes  to  deceive,  she  may  assert 


THE  SIGNS  AND  DIAGNOSIS  OF  PREGNANCY.  185 

them,  and,  if  she  wishes  to  conceal,  she  may  deny  them — yea,  many  a 
woman  in  the  agony  of  childbirth,  or  in  the  very  article  of  death,  has 
denied  her  pregnancy  with  the  vain  hope  of  protecting  her  good  name 
from  reproach,  or,  more  frequently,  for  the  purpose  of  saving  her  seducer 
from  exposure. 

Ambition  to  give  a  prompt  decision,  or  pride  in  opposing  that  of 
another,  may  lead  to  error.  Rapidity  is  very  far  from  proving  correct- 
ness of  diagnosis  ;  here,  as  Lord  Bacon  has  said  of  another  matter, 
our  intellects  need  not  wings  but  weights  of  lead  to  moderate  their 
course.  The  man  of  greatest  knowledge  least  exalts  his  attainments, 
and  is  the  most  cautious  and  deliberate  in  judgment,  and  has  respect 
for  the  opinions  of  others.  Sloth  may  hinder  or  prevent  our  thorough 
investigation.  We  may  be  satisfied  with  a  few  facts  instead  of  seeking 
all  that  are  available.  We  may  give  undue  weight  to  one  or  more  of 
these  facts,  undervaluing  or  neglecting  others.  In  illustration  some  cases 
that  have  been  under  my  own  observation  will  be  given  :  A  young  lady 
of  high  social  position,  and  against  whose  purity  there  was  no  whisper 
or  thought  of  scandal,  is  attacked  with  obstinate  vomiting.  There  is  a 
denial  of  menstrual  derangement;  the  vomiting  resists  all  remedies, 
and  she  dies,  but  while  dying  a  fetus  of  three  months  and  a  half  is 
expelled.  A  woman  having  passed  twenty  years  of  married  life  child- 
less, some  months  after  the  menopause  becomes  pregnant ;  the  pregnancy 
is  suspected  by  one  attendant,  and  denied  by  another.  Nieden  (Cent. 
fur  Geburt.,  1889)  gives  an  instance  of  pregnancy  after  twenty-six  years 
of  marriage  (married  at  eighteen).  The  writer  has  had  a  patient  who 
was  ten  years  married  before  giving  birth  to  a  child ;  during  these 
years  her  health  was  perfect,  and  there  was  apparently  no  reason  for 
her  delayed  maternity.  A  girl  who  has  never  menstruated,  and  who 
does  not  fully  present  the  other  signs  of  puberty,  becomes  pregnant 
by  violence,  and  gives  birth  to  a  child  when  she  is  twelve  years 
old.  A  woman  has  menstrual  suppression,  coincident  abdominal  en- 
largement, the  mammary  and  many  other  signs  of  pregnancy,  but  a 
post-mortem  examination  proves  cystic  disease  of  the  ovary.  A  girl 
of  twenty  has  never  menstruated ;  her  abdomen  enlarges,  her  breasts 
are  swelled  and  secrete  ;  after  a^time  severe  uterine  contractions  occur, 
and  a  physician  of  large  experience  called  to  her  during  this  attack 
declares  she  is  in  labor;  the  cause  of  the  abdominal  enlargement  is 
accumulation  of  many  months'  menstrual  secretion,  and  the  uterine 
contractions  simulating  labor-pains  are  the  efforts  to  overcome  the  resist- 
ance of  an  imperforate  hymen. 

Time  would  fail  to  give  all  the  published  cases  in  which  a  pregnant 
uterus  has  been  tapped,  or  even  abdominal  section  made  for  its  removal, 
because  it  was  thought  an  ovarian  tumor,  and  many  a  patient  has  been 
saved  from  such  perils  because  of  the  postponement  of  the  operation 
until  happily  labor  prevented  its  performance ;  the  unpublished  instances 
of  such  errors  are  much  more  numerous. 

Pajot1  states  that  he  has  seen  a  pregnancy  of  four  months  taken  for 
an  abscess,  and  the  uterus  opened  by  a  bistoury,  introduced  into  the 
vagina,  by  one  of  his  old  masters,  the  most  learned  and  venerated.  But 

1  Travaux  d'Obstetrique  et  de  Gynecologic. 


186  PHYSIOLOGY  OF  PREGNANCY. 

it  is  not  necessary  to  multiply  instances  of  wrong  diagnosis  leading  to 
an  assertion  of  pregnancy  when  it  does  not  exist,  or  a  denial  of  it  where 
it  is  present.  Tardieu1  has  said  that  all  signs  of  true  pregnancy,  except 
the  bruit  of  the  foetal  heart,  may  be  observed  when  there  is  no  preg- 
nancy, from  the  development  of  the  abdomen  and  breasts  up  to  move- 
ments and  the  efforts  of  labor.  It  is  not  wonderful,  then,  that  mistakes 
have  been  made,  and  yet  in  most  cases  they  are  avoidable. 

Liability  to  error  is  caused  by  the  pregnancy  being  abnormal,  or  by 
its  complication  with  some  pathological  enlargement,  for  example,  ascites, 
ovarian  tumor,  or  uterine  fibroid ;  but  these  topics  will  be  considered 
elsewhere.  Concluding  the  subject  of  diagnostic  errors  as  to  pregnancy, 
the  practitioner  who  would  avoid  them  must  faithfully  interrogate  all 
the  changes,  both  organic  and  functional,  in  the  maternal  organism,  and 
those  which  are  caused  by  foetal  development;  he  must  be  patient, 
thorough,  painstaking  in  his  investigation,  not  hasty,  partial,  and  super- 
ficial ;  he  must  be  willing  to  delay  his  decision  in  all  doubtful  cases, 
rather  than  run  the  risk  of  a  happy  guess,  or  trust  an  average  of  prob- 
abilities. Many  other  errors  in  diagnosis  may  never  come  to  the  light, 
but  time  is  the  certain  and  remorseless  revealer  of  these;  alike  the 
asserted  pregnancy  which,  like  the  weaving  of  Penelope's  web,  never 
ends,  and  the  denied  pregnancy  which  in  a  few  weeks  or  months  a 
babe's  first  cry  contradicts,  are  too  often  made  known,  to  the  disap- 
pointment if  not  disgrace  of  the  hasty  diagnostician. 

CLASSIFICATION  OF  THE  SIGNS  OF  PREGNANCY.  These  may  be 
conveniently  divided  into  the  subjective  and  the  objective.  The  former 
include  the  information  we  can  get  from  the  person  herself — all  the 
answers  she  makes  to  our  inquiries  as  to  the  functional  changes  caused 
by  pregnancy,  and  as  to  the  various  new  sensations  she  experiences ;  she 
tells  us  what  she  knows,  or  believes  she  knows.  By  objective  signs,  we 
mean  those  discovered  by  our  own  senses,  the  special  avenues  of  certain 
knowledge ;  we  may,  or  we  may  not,  believe  what  another  tells  us,  but 
that  which  we  see  with  our  own  eyes,  hear  with  our  own  ears,  and  handle 
with  our  own  hands,  commands  our  credence.  The  subjective  signs  will 
be  considered  first. 

MENSTRUATION  is  ABSENT.  The  absence  of  menstruation  is  a  sign 
of  great  value  in  the  case  of  a  woman  hitherto  regular,  there  being  no 
pathological  cause  for  the  suppression  and  no  pathological  result  from 
it;  the  sign  increases  in  value  each  month  that  it  continues.  But  con- 
ception may  occur  during  lactation,  in  the  first  nine  or  ten  months  of 
which  menstruation  is  normally  absent,  or  it  may  take  place  before  any 
flow  has  been  observed ;  as  La  Motte  said,  a  woman  may  have  fruit 
before  flowers,  and  in  such  cases  of  course  the  sign  is  without  value. 
Again,  a  monthly  flow  may  occur  once  or  oftener  after  conception,  even 
continue  during  the  entire  pregnancy ;  and  stranger  still  are  those  rare 
cases  of  this  hemorrhage  occurring  in  women  only  when  pregnant. 
Naegele  and  Greuser,2  referring  to  menstruation  in  pregnancy,  state 
that  sometimes  the  flow  does  not  differ  in  type,  quality,  and  quantity 
from  ordinary  menstruation.  But  the  general  law  is  that  the  pregnant 

1  Sur  les  Grossesses  Fausses  et  Simulees. 

2  Traite  Pratique  de  1'Art  des  Accoucheinents.    Translated  by  Aubenas.    Paris,  1880. 


THE  SIGNS  AND  DIAGNOSIS  OF  PREGNANCY.  187 

woman  does  not  menstruate,  and  the  apparent  exceptions  to  this  law 
are  very  few.  Nature,  when  building  up  the  foetus,  has  no  excess  of 
material  to  be  periodically  discharged,  and  the  intimate  union  which  is 
established  early  in  pregnancy  between  the  ovum  and  the  uterine  mucous 
membrane  prevents  the  latter  being  normally  a  source  of  hemorrhage, 
whether  irregular  or  periodical.  Further,  ovulation  is,  as  a  rule,  absent 
in  pregnancy,  and  in  like  manner  the  associated  or  resulting  hemorrhage 
ought  to  be  absent.  Hemorrhages  from  the  uterus  of  a  pregnant  woman 
are  pathological,  not  physiological,  and  generally  threaten  abortion  or 
premature  labor,  and  should  be  so  considered  and  so  treated.  Rarely 
will  one  be  deceived,  says  Stoltz,1  who  regards  a  woman  menstruating 
regularly,  with  all  the  characters  of  menstruation,  as  not  pregnant, 
while  trusting  the  contrary  opinion  he  is  exposed  to  frequent  errors. 

NAUSEA  AND  VOMITING — SALIVATION.  Gastric  disturbance  is  one 
of  the  most  frequent  symptoms  of  pregnancy,  and  in  rare  cases  it  begins 
about  the  time  of  conception.  As  illustrating  the  last  statement,  the 
following  report  of  a  case  by  the  late  Dr.  Montgomery  is  of  interest : 
"  I  attended  a  patient  who  was  married  on  Monday,  and  began  to  be 
squeamish  on  Saturday ;  her  delivery  took  place  within  nine  months." 
If  the  nausea  and  vomiting  be  associated  with  menstrual  suppression, 
if  the  disturbance  occur  at  a  regular  time  each  day  without  any  other 
pathological  symptom,  and  if  food  is  vomited  soon  after  it  is  taken,  and 
the  appetite  is  unimpaired,  this  sign  has  great  value.  Copious  secretion 
of  saliva  occurs  in  some  cases,  but  it  is  not  very  frequent ;  it  generally 
accompanies  excessive  nausea  and  vomiting,  though  it  may  also  occur 
when  these  symptoms  are  absent  or  insignificant.  The  late  Dr.  Dewees 
attached  great  importance  to  spitting  a  white,  frothy  mucus — "  cotton- 
spitting  " — as  a  sign  of  pregnancy. 

NERVOUS  DISORDERS.  Changes  in  the  disposition,  increased  sensi- 
bility, despondency,  etc.,  are  of  no  value  as  signs  of  pregnancy,  "  for 
they  are  often  just  as  great  when  a  woman  believes  herself  pregnant," 
the  event  proving  her  mistake,  as  when  she  is  pregnant.  The  different 
forms  of  neuralgia  from  which  pregnant  women  sometimes  suffer  may 
occur  to  the  non-pregnant. 

MAMMARY  PAINS  AND  SWELLINGS.  Pains  in  the  breasts  and  some 
enlargement  of  these  organs,  with  possibly  a  slight  secretion,  will  prob- 
ably be  observed  by  most  women  early  in  pregnancy,  but  all  these 
symptoms  may  occur  in  girls  and  women  who  are  not  pregnant.  Many 
females  have  more  or  less  mammary  pain  and  swelling  in  connection 
with  menstruation. 

IRRITABILITY  OF  THE  BLADDER— LEUCORRHCEA.  It  is  not  un- 
common for  women  in  the  first  part  of  gestation  to  have  some  irritability 
of  the  bladder  and  increased  mucous  discharge  from  the  sexual  organs. 
While  inquiry  may  be  made  concerning  tnese  symptoms,  but  little 
importance  is  to  be  attached  to  them  alone,  for  there  are  so  many  other 
conditions  in  which  they  may  be  found. 

QUICKENING.  Certain  sensations  perceived  by  the  mother  were 
believed  to  mark  the  time  when  the  foetus  was  endued  with  life  and 
soul,  and  the  woman  was  then  "  quick  with  child  ;"  this  distinction  was 

1  Op.  cit. 


188  PHYSIOLOGY  OF  PREGNANCY. 

recognized  alike  by  physicians  and  by  courts.  We  now  know  that  the 
child's  life  begins  with  the  union  of  spermatozoid  and  ovule;  then  and 
there  was  the  quickening  power,  then  the  true  creation,  and  the  young 
life  in  its  dim  dawn  is  as  real  and  sacred  as  in  its  maturity. 

The  phenomenon  commonly  called  quickening  usually  occurs  between 
the  first  and  the  middle  of  the  fifth  mouth,  but  in  rare  cases  it  is  noticed 
earlier,  in  others  later,  and  in  still  others  it  is  absent  during  the  entire 
pregnancy. 

Different  opinions  have  been  held  as  to  its  cause.  By  some  it  is 
attributed  to  the  direct  contact  of  the  uterus  with  the  abdominal  wall. 
Tyler  Smith  believed  the  sensations  due  to  the  first  peristaltic  actions  of 
the  uterus,  and  regarded  the  date  of  quickening  as  marking  the  time 
when  the  contractile  tissue  of  this  organ  is  so  far  developed  as  to  admit 
of  these  contractions.  The  opinion  generally  received  is  that  it  is  caused 
by  the  movements  of  the  foetus  that  are  first  recognized  by  the  mother  ; 
they  are  not  felt  until  the  uterus  rests  upon  the  abdominal  wall,  and 
they  are  felt  through  it,  and  not  immediately  in  the  wall  of  the  uterus. 
Of  course,  foetal  movements  are  made  much  earlier,  and  they  can  be 
recognized  by  the  stethoscope  before  the  mother  is  conscious  of  them. 
The  value  of  this  sign  of  pregnancy  is  lessened  not  only  by  the  fact 
previously  mentioned,  that  pregnancy  may  be  completed  without  the 
mother  ever  having  been  conscious  of  them,  but  by  this,  that,  as 
Hamilton  said,  no  woman  ever  yet  fancied  herself  pregnant  without 
persuading  herself  she  felt  the  movements  of  the  child.  Nay,  more,  a 
woman  after  repeated  experience  as  to  the  sensation  in  question  may, 
with  the  best  faith  in  the  world,  assert  she  feels  these  movements,  and 
yet  not  be  pregnant.  Dr.  Blundell1  mentions  a  case  under  his  own  care 
of  a  woman  who  had  given  birth  to  twelve  children,  and  who  believed 
herself  again  pregnant,  declaring  she  felt  the  movements  of  the  child  as 
plainly  as  she  had  in  any  of  her  previous  pregnancies,  and  yet  she  was 
not  pregnant. 

The  story  of  the  supposed  pregnancy  of  Queen  Mary,  of  England, 
and  that  of  Joanna  Southcote,  furnish  illustrious  instances  of  self- 
deception  in  regard  to  the  sensation  of  fcetal  movements. 

OBJECTIVE  SIGNS.  These  are  sought,  not  by  inquiries,  but  by  direct 
examination  of  the  patient ;  they  are  not  her  statements,  but  facts  and 
conditions  directly  recognized  by  our  own  senses. 

INSPECTION.  We  observe  the  patient's  countenance  as  to  whether 
anxious,  haggard,  expressive  of  suspicion,  or  indifference ;  her  face  as 
to  whether  full  and  florid,  or  pale,  thin,  and  emaciated,  and  as  to  the 
presence  or  absence  of  discolorations.  When  the  patient  is  standing  or 
walking  it  is  well  to  notice  the  position  of  the  shoulders,  the  increased 
lumbar  curve,  and  the  abdominal  prominence.  Examination  of  the 
naked  abdomen  may  show  stria?  and  pigmentation,  and  changes  in  the 
umbilicus,  a  deeper  or  effaced  cavity,  or  umbilical  pouting.  The  labia 
majora  may  be  found  swelled  and  firmer,  and  presenting  greater  or  less 
discoloration,  and  the  vaginal  mucous  membrane  purplish.  Never- 
theless, visual  examination  of  these  parts  is  not  necessary  in  most  cases 

i  Principles  and  Practice  of  Obstetricy. 


THE  SIGNS  AND  DIAGNOSIS  OF  PREGNANCY.  189 

of  supposed  pregnancy.  Exposure  of  one  of  the  mammary  glands  is 
less  trying  to  the  subject,  and  furnishes  more  important  information. 
Is  the  breast  larger  and  firmer  than  usual  ?  Is  the  nipple  more  promi- 
nent and  harder,  and  can  a  fluid  be  pressed  from  it  ?  The  areola  is  to 
be  closely  observed  as  to  whether  swelled  and  darkened,  and  as  to 
hypertrophy  of  its  tubercles ;  supposing  the  primary  areola  to  have 
undergone  the  characteristic  changes  of  pregnancy,  if  the  gestation  has 
lasted  five  months,  the  secondary  areola  is  beginning  to  appear.  The 
urine  may  be  examined  as  to  the  presence  of  kyestein,  or  as  to  the 
lessened  quantity  of  its  solid  constituents ;  but  such  examination  is  of 
scientific  interest  rather  than  of  practical  value.  Jorissenne's  "  sign  " 
may  be  tried,  the  pulse  counted  when  the  woman  is  standing,  then 
sitting,  and,  finally,  when  lying.1 

TOUCH.  The  obstetric  definition  of  touch  is  a  digital  or  manual 
examination  of  the  female  internal  and  external  generative  organs  and 
adjacent  parts  for  diagnostic  or  therapeutic  purposes.  Touch  may  be 
vaginal,  rectal,  vesical,  or  abdominal.  In  the  first  three  it  is  almost 
always  digital,  but  in  the  last  it  is  usually  manual,  and  commonly  called 
palpation;  sometimes  vaginal  touch  and  abdominal  palpation  are  com- 
bined, and  this  is  bi-manual  or  abdomino-vaginal  examination. 

VAGINAL  TOUCH.  This  is  usually  made  with  the  index-finger  of 
the  right  or  of  the  left  hand,  whichever  may  be  the  more  convenient 
with  reference  to  the  position  of  the  patient;  while  the  right  hand  is 
generally  used,  there  are,  as  Cazeaux  has  said,  some  diseases  of  women 
and  some  positions  of  the  foetus  which  compel  the  accoucheur  to  use  the 
left  hand,  and  therefore  he  should  accustom  himself  to  touching  with 
either  hand.  Some  practitioners  prefer  to  join  the  medius  to  the  index, 
thereby  gaining,  according  to  Stein,  a  little  more  than  half  an  inch,  15 
millimetres  ;  a  gain  of  an  inch  is  impossible.  But  if  two  fingers  are  used, 
the  examination  may  be  quite  painful  in  a  primigravida,  and  the  sensa- 
tion given  the  examiner  by  two  fingers  is  less  clear  than  that  from  one  ; 
beside,  the  index  can  be  more  easily  separated  from  the  adjoining  finger, 
and  thus  can  explore  a  greater  part  of  the  pelvic  capacity. 

Hubert,  who  happily  characterizes  the  accoucheur's  finger  as  clairvoyant?  states 
that  in  some  localities  in  Holland  accoucheurs  and  sages-femmes  have  for  their 
sign  a  representation  of  a  long  finger  surmounted  by  an  eye.  A  similar  device 
was  placed  by  the  late  Dr.  Valentine  Mott  upon  the  tickets  of  admission  to  his 
lectures  in  the  University  of  New  York. 

The  practitioner  must  carefully  notice  if  there  is  the  slightest  abra- 
sion upon  the  finger  used  in  touching,  or  upon  the  other  fingers  of  the 
hand,  and  if  there  be  he  should  cover  the  abraded  part  with  collodion 
or  other  protective  material ;  if  he  neglects  this  precaution,  he  may,  even 

1  Jorissenne  (Nouveau  Signe  de  la  Grossesse)  states  that  in  the  first  months  of  gestation,  in  the 
ahsence  or  uncertainty  of  other  signs  of  the  pregnant  condition,  an  important  one  is  furnished  by 
the  fact  that  the  pulse  does  not  correspond  with  the  changes  of  position,  but  remains  the  same 
whether  the  person  is  erect,  sitting,  or  lying  down.    Fry  (American  Journal  of  Obstetrics,  1884)  has 
not  found  this  sign  of  any  value     More  recently  and  from  quite  extensive  observations,  Louge 
(Le  Pouls  Puerperal  Physiologique)  found  the  sign  only  occasionally  present,  and  then  after  the 
fifth  month,  when  other  signs  of  pregnancy  generally  make  the  diagnosis  quite  easy. 

Fry  regards  Cop  cit.)  a  vaginal  temperature  of  0.7°  above  that  of  the  axilla  as  presumptive  of 
pregnancy,  if  there  is  no  fever  or  local  disease. 

2  Cours  d'Accouchements,  professe  i\  1'Universite  Catholique  de  Louvain,  1878 


190  PHYSIOLOGY  OF  PREGNANCY. 

from  a  patient  In  regard  to  whom  he  has  not  the  slightest  suspicion  of 
such  disease,  be  inoculated  with  the  poison  of  syphilis  ;  many  a  physician 
in  the  discharge  of  his  obstetric  duties  has  become  the  subject  of  syphi- 
litic infection  from  not  taking  proper  precautions  in  a  vaginal  exami- 
nation. 

SUBJECTIVE  AND  OBJECTIVE  DISINFECTION.  The  thorough  cleans- 
ing of  the  hands,  especially  of  the  fingers  of  which  are  brought  in 
contact  with  the  genital  organs,  is  very  important  preliminary  to  an 
internal  examination.  The  nails  should  be  short  and  thoroughly 
cleansed.  The  hands  are  washed  for  five  minutes  in  warm  water  and 
soap,  a  nail-brush  being  industriously  used.  Sanger's  method,  using 
green  soap  and  sand,  is  excellent.  After  the  washing  the  hands  may  be 
immersed  in  a  solution  of  corrosive  sublimate,  one  part  to  1000,  for  two 
minutes.  Then  they  may  be  dipped  in  a  mixture  of  creolin  and  water, 
3  to  5  per  cent.,  or  a  solution  of  lysol,  \  to  one  per  cent.  The  employ- 
ment of  creolin  or  of  lysol  renders  unnecessary  the  application  of  any 
ointment  to  the  examining  finger.1 

So  far  as  objective  disinfection  is  concerned,  it  would  be  better  in  all 
cases  if  the  vagina  be  irrigated  with  a  solution  of  lysol  having  the 
strength  previously  mentioned,  or  a  creolin  mixture,  half  a  teaspoonful 
to  one  pint  and  a  half  of  water.  In  some  cases,  those  in  which  there 
is  a  purulent  discharge,  this  previous  irrigation  is  absolutely  essential, 
and,  indeed,  in  addition  to  one  of  the  antiseptics  mentioned,  the  vagina 
should  be  well  washed  with  a  solution  of  corrosive  sublimate,  one  part 
to  2000. 

PEEPARATION  AND  POSITION  OF  THE  PATIENT — EXAMINATION. 
— The  patient  must  have  been  further  prepared  by  having  the  bowels 
and  bladder  recently  emptied,  and  her  clothing  quite  loose.  The  exami- 
nation may  be  made  when  she  is  standing  or  when  she  is  lying.  If 
made  in  the  former  position,  her  back  should  be  against  the  wall  or 
some  high,  firm  body,  and  the  physici^u  faces  her,  either  sitting  upon  a 
low  stool  or  resting  one  knee  upon  the  floor — the  right  knee  if  the  left 
index  finger  is  used — the  other  knee  furnishing  a  support  for  the  elbow 
of  the  hand  which  touches.  In  the  erect  position  the  pressure  of  the 
intestines  and  the  contraction  of  the  abdominal  muscles  force  the  uterus 
somewhat  lower ;  hence,  in  some  women  who  are  very  fat,  it  is  difficult 
to  reach  the  os  uteri  if  they  are  lying,  and  the  examination  may  have  to 
be  made  in  the  former  position  ;  so,  too,  this  position  is  more  favorable 
for  vaginal  ballottemeut.  But  in  most  cases  the  examination  is  made 
when  the  patient  is  lying.  She  should  be  on  her  back,  lightly  covered, 
the  thighs  and  legs  flexed  ;  the  bed  should  be  of  such  firm  material  that 
her  hips  will  not  sink  in  it,  or  they  should  be  raised  by  placing  under 
them  three  or  four  thicknesses  of  blanket  or  a  hair  cushion.  The  phy- 
sician now  takes  his  seat  or  kneels  by  that  side  of  the  bed  nearest  which 
the  patient  is — if  it  be  the  right  side,  his  right  hand  is  used  in  the  exami- 
nation— extends  the  thumb  and  index  finger,  flexes  the  others,  and 
introduces  the  hand  under  the  clothes  of  the  bed  and  of  the  patient, 

1  The  question  of  disinfection  will  be  further  considered  in  connection  with  attendance  upon  labor. 


THE  SIGNS  AND  DIAGNOSIS  OF  PREGNANCY.  191 

touching  the  middle  of  the  inner  surface  of  the  knee  next  him  with  the 
extended  thumb,  then  by  following  a  line  parallel  with,  and  equidistant 
from  the  thighs,  his  finger  readily  finds  the  vulval  orifice,  or  this  may  be 
entered  by  first  carrying  the  hand  directly  to  the  perineum,  and  then 
slightly  raising  the  finger  in  the  median  line.  Whichever  plan  of  reach- 
ing the  vulval  opening  is  followed,  it  is  very  much  better,  the  examina- 
tion is  easier,  and  the  movements  of  the  finger  more  free,  if  the  forearm, 
instead  of  crossing  beneath  the  thigh,  is  introduced  under  the  clothing 
so  far  as  to  lie  in  a  longitudinal  direction.  Some  obstetricians  advise 
passing  the  hand  over  the  thigh  of  the  patient,  but  this  practice  does 
not  so  well  secure  her  immobility  and  relaxation  of  the  abdominal  wall; 
the  latter  is  an  important  point  if  one  failing  to  reach  the  os  uteri,  for 
example,  or  other  part  of  which  exploration  is  desirable,  wishes  to  press, 
with  the  free  hand  upon  the  abdomen,  the  uterus  toward  the  pelvic  cavity. 
Before  the  finger  is  passed  into  the  vagina  the  condition  of  the  vulva 
may  be  learned,  especially  as  to  swelling  from  oedema,  varices,  or  inflam- 
mation ;  it  may  be  necessary  subsequently  to  examine  with  the  eye  in 
case  he  finds  such  conditions.  When  the  finger  is  passed  into  the  vagina 
the  state  of  this  organ  should  be  carefully  noted  as  to  size,  temperature, 
secretion,  sensibility,  and  form.  Next  the  examination  of  the  pelvis 
and  uterus  is  made.  Of  course,  any  considerable  encroachment  upon 
the  pelvic  diameters  by  a  new  growth  or  by  change  in  the  bones  could 
be  readily  ascertained.  Such  pathological  growths  and  deformities  are 
rare  exceptions,  and  the  physician's  constant  and  generally  only  concern 
is  the  condition  of  the  uterus.  His  first  effort  is  to  find  the  os  uteri, 
and  this  is  not  in  all  cases  easy  to  do.  Remembering  the  usual  right 
antero-lateral  position  of  the  body  of  the  uterus  in  pregnancy,  the  os 
would  be  directed  backward  to  the  sacral  cavity  and  to  the  left  side ;  it 
may  be  impossible  to  reach  it  while  the  patient  is  lying  upon  her  back  ; 
nevertheless  an  effort  should  be  made,  first  having  her  hips  still  more 
elevated,  and  by  pressing,  with  one  hand  upon  the  abdomen,  the 
uterus  backward  and  toward  the  median  line;  if  this  fail,  the  woman 
is  directed  to  turn  upon  the  side  opposite  to  that  of  the  latero- version, 
the  finger  during  this  change  of  position  being  retained  in  the  vagina, 
and  generally  the  os  uteri  may  then  be  felt.  The  changes  in  the  cervix 
and  os  caused  by  pregnancy  have  previously  been  stated,  and  therefore 
no  further  reference  to  them  is  necessary. 

SANGER'S  SIGN.  Sanger  has  called  attention  to  the  condition  of  the 
ureters  in  pregnancy  as  felt  by  vaginal  examination.  They  are  more 
prominent,  larger,  and  more  resistant.  Certainly  those  who  have  had 
the  opportunity  of  making  this  examination  under  his  direction  must 
be  impressed  with  the  value  of  this  sign  of  pregnancy. 

EXAMINING  THE  BODY  OF  THE  UTERUS.  Examination  of  the 
body  of  the  uterus,  as  far  as  it  can  be  reached  by  the  finger  in  the  vagina, 
assisted  by  pressure  upon  the  abdomen,  is  made ;  if  the  organ  has  changed 
its  form  so  that  the  finger  passes  somewhat  abruptly  from  the  nearly 
cylindrical  cervix  to  a  round,  expanded  body,  and  if  its  walls  are  elastic, 
depressible,  and  yielding,  the  probability  is,  the  uterine  enlargement  is 
caused  by  pregnancy.  This  sign  is  one  of  the  earliest  that  is  available, 


192  PHYSIOLOGY  OF  PREGNANCY. 

and  one  which,  if  not  deserving  to  be  ranked  among  the  certain  signs, 
yet  gives  a  high  degree  of  probability.1 

BALLOTTEMENT.  In  obstetrics  this  word  means  the  sensation  which 
the  examiner  experiences  when  he  communicates  a  sudden  movement 
to  the  whole  or  to  a  part  of  the  foetus ;  repercussion  is  sometimes  used 
as  a  synonym.  It  is  the  result  of  a  momentary  displacement  of  a  solid 
body  in  a  liquid ;  just  as  one  by  striking  a  lump  of  ice2  in  a  tumbler 
of  water  with  the  finger  causes  it  to  recede — and  the  experiment  would 
be  the  same  if  a  finger-tap  were  made  through  a  membrane  fastened 
over  the  tumbler — so  an  impulsion  is  made  upon  the  foatus  or  a  part  of 
it.  If  the  entire  foatus  be  displaced,  and  the  finger  be  retained  at  the 
point  where  this  movement  was  produced,  the  return  of  the  foetus  may 
also  be  recognized,  and  the  sensation  thus  caused  is  known  as  the  choc 
de  retour.  It  is  thus  seen  that  there  may  be  a  single  sensation  experi- 
enced in  ballottement,  and  this  is  the  more  frequent,  or  a  double  sensa- 
tion. 

Ballottement  is  either  abdominal  or  vaginal ;  the  former  will  be  con- 
sidered hereafter.  In  vaginal  ballottemeut  the  woman  is  either  standing 
or  lying.  The  physician  should,  in  the  former  case,  pass  one  or  two 
fingers  into  the  vagina,  and  in  front  of  the  cervix,  until  they  rest  upon 
the  body  of  the  womb  at  its  junction  with  the  former ;  the  free  hand  is 
applied  to  the  fundus  of  the  uterus,  and  then  a  quick  movement  is  made 
by  the  finger  or  fingers  in  the  vagina,  a  sudden  impulse  thus  communi- 
cated to  the  foetus,  dislodging  it  from  its  position  and  causing  it  to 
float  upward  in  the  uterine  cavity  ;  the  return  of  the  foetus  may  be  felt 
in  many  cases,  that  is,  unless  this  return  be  very  gradual,  or  in  those 
cases  in  which  only  a  part  of  the  foetus  has  been  displaced.  If  the 
woman  be  lying,  it  is  well  for  her  to  have  the  head  and  shoulders  some- 
what raised,  so  as  to  throw  the  uterus  forward,  and  then  the  ballotte- 
ment  may  besought  jusl  as  if  she  were  erect ;  if  she  be  quite  horizontal, 
the  finger  must  be  passed  into  the  posterior,  instead  of  into  the  anterior, 
cul-de-sac. 

Ballottement  is  an  almost  positive  proof  of  pregnancy  ;  nevertheless, 
Pajot  found  it  present  in  a  woman  who  was  not  pregnant,  but  had  a 
multilocular  ovarian  cyst.  The  absence  of  ballottement  does  not  prove 
that  woman  is  not  pregnant ;  for  great  size  or  small  size  of  the  foetus, 
plural  pregnancy,  polyhydramnios,  placental  or  shoulder  presentation 
may  prevent  it.  A  ballottement  caused  by  entire  displacement  of  the 
foetus,  though  recognizable  at  about  five  months,  is  best  perceived  in 
the  sixth  and  seventh  months,  and  that  from  a  partial  displacement  later. 
But  before  the  date  when  ballottemeut  is  readily  done  signs  of  preg- 
nancy are  available  which  are  certain. 

KECTAL  AND  VESICAL  TOUCH,  HEGAR'S  SIGN.  Eectal  touch  may 
be  necessary  in  case  of  vulval  or  of  vaginal  obstruction,  in  posterior 
displacements  of  the  uterus,  and  in  the  diagnosis  of  tumors  of  the  recto- 
vaginal  wall,  of  effusions  in  Douglas's  cul-de-sac,  and  of  extra-uterine 

1  Before  attempting  the  certain  diagnosis  of  pregnancy  in  the  first  months  it  may  be  well  to 
recall  the  caution  which  Dr.  Wm.  Hunter  manifested  :  "  I  cannot  determine  at  four  months  ;  I 
am  afraid  of  myself  at  five  months ;  but  when  six  or  seven  months  are  over,  I  urge  an  examina- 
tion."   Of  course,  this  is  extreme,  for  it  is  only  in  exceptional  cases  that  a  positive  diagnosis  cannot 
be  made  in  the  fifth  month. 

2  Tarnier. 


THE  SIGNS  AND  DIAGNOSIS  OF  PREGNANCY. 


193 


pregnancy.  It  is  a  method  of  examination  very  repulsive  to  the  subject, 
and  is  rarely  necessary.  Vesical  touch  or  examination  through  the 
bladder,  the  urethra  having  been  previously  dilated  to  admit  the  finger, 
permits  examination  of  the  anterior  wall  of  the  uterus ;  it  is  rarely  re- 
quired. 

The  sign  of  pregnancy  known  as  Hegar's,  is  softening  and  thinning 
of  that  part  of  the  uterus  immediately  above  the  cervix.  This  condi- 
tion may  be  recognized  by  introducing  the  index  finger  of  one  hand 
into  the  rectum  above  the  utero-sacral  ligaments,  pressing  directly  up- 
ward, the  patient  lying  upon  her  back  ;  three  fingers  of  the  other  hand 
press  firmly  upon  the  abdominal  wall  just  above  the  pubes,  so  that  they 
are  brought  in  approximation  with  the  rectal  finger  :  the  thinning  of  the 
lower  portion  of  the  uterus  is  thus  discovered. 

Sonntag1  has  published  fifty  cases  in  which  diagnosis  of  pregnancy  was  made 
by  Hegar's  sign.  But  for  this  examination  anaesthesia  is  usually  required,  and, 
moreover,  in  some  instances  it  has  been  followed  by  abortion.  Diagnosis  in  the 
second  or  third  month  of  pregnancy  can  only  exceptionally  be  necessary. 

ABDOMINAL  TOUCH,  OR  PALPATION.  This  consists  in  the  applica- 
tion of  the  hands  to  the  abdomen  for  the  diagnosis  of  pregnancy  and 

FIG.  103. 


THE  HAND  CIRCUMSCRIBING  THE  FUNDUS  OF  THE  UTERUS  IN  PALPATION. 

its  duration,  to  ascertain  whether  it  be  single  or  plural,  the  presentation 
and  position  of  the  foetus,  and  for  the  correction  of  an  unfavorable 
presentation. 

The  woman,  her  bowels  and  bladder  having  previously  been  evacu- 
ated, lies  upon  her  back,  with  her  limbs  extended ;    the  abdomen  is 

1  Das  Hegar'sche  Schwangerschaftszeichen.  Leipzig,  1892. 
13 


194 


PHYSIOLOGY  OF  PREGNANCY. 


exposed  from  the  epigastrium  to  the  mons  veneris.  The  physician, 
having  previously  warmed  his  hands  if  they  are  cold,  takes  his  position 
at  that  side  of  the  bed  nearest  which  she  is  lying — the  left  is  the  better 
— and  places  one  of  his  hands  upon  the  hypogastrium,  keeping  it  pressed 
there  flat  and  with  moderate  firmness  for  two  or  three  minutes  in  order 
to  accustom  the  abdominal  muscles  to  this  contact,  and  thus  obviate 
their  contraction.  So,  too,  if  the  pregnancy  be  well  advanced,  uterine 
contraction  may  be  excited  by  the  hand;  during  it  all  pressure  should 
cease.  The  first  object  in  palpation  is  to  learn  the  presence  and  the  size 
of  the  uterus,  and  to  do  this  let  the  left  hand,  if  the  physician  is  upon 
the  patient's  right  side,  be  pressed  with  the  fingers  and  thumb  slightly 
flexed  so  as  to  correspond  to  the  convex  surface  of  the  uterus  upon  the 
hypogastrium,  and  gradually  carry  the  hand  further  up  the  abdominal 
wall,  each  movement  of  ascent  marked,  first,  by  relaxed,  then  increased 
pressure,  and  the  pressure  being  stronger  at  the  ulnar  margin  of  the 
hand,  so  that  when  the  fundus  of  the  uterus  is  reached  that  part  at  once 

FIG.  104. 


recognizes  the  failure  of  resistance  and  dips  deeper  in  the  abdominal 
cavity.  Another  method  is  by  using  both  hands  held  almost  vertically 
so  that  the  fingers  begin  pressing  upon  the  hypogastrium  in  the  median 
line,  then  the  hands  are  gradually  separated,  the  space  widened  between 
them  until  the  fingers  meeting  with  no  resistance  may  be  passed  down 
on  each  side  of  the  uterus ;  the  sides  of  the  uterus  can  now  be  followed 
up  until  the  fundus  is  reached.  We  recognize  the  uterus  by  its  form, 
by  its  position,  and  possibly  by  its  being  the  seat  of  intermittent  con- 
tractions ;  further  in  cases  of  doubt,  while  one  hand  circumscribes  the 
supposed  fundus,  a  finger  of  the  other  may  be  passed  into  the  vagina, 
so  as  to  touch  the  cervix,  and  the  continuity  of  this  with  the  mass  felt 


THE  SIGNS  AND  DIAGNOSIS  OF  PREGNANCY.  195 

through  the  abdominal  wall  can  be  easily  ascertained.  The  distance  of 
the  fundus  above  the  pubic  symphysis,  supposing  the  woman  to  be  preg- 
nant, enables  an  approximate  determination  of  the  time  of  the  pregnancy. 

Intermittent  contractions  of  the  uterus  ascertained  by  palpation  have 
been  especially  studied  by  Dr.  Braxton  Hicks,  and  he  states  that  this 
sign  is  available  by  the  last  of  the  third  month.1  "  If  then  the  uterus 
be  examined  without  friction  or  any  pressure  beyond  that  necessary  for 
full  contact  of  the  hand  continuously  over  a  period  of  from  five  to 
twenty  minutes,  it  will  be  noticed  to  become  firm  if  relaxed  at  first,  and 
more  or  less  flaccid  if  it  be  firm  at  first.  It  is  seldom  that  so  long  an 
interval  occurs  as  that  of  twenty  minutes ;  most  frequently  it  occurs 
every  five  or  ten  minutes,  sometimes  even  twice  in  five  minutes.  How- 
ever, in  some  cases,  I  have  found  only  one  contraction  in  thirty  minutes. 
The  duration  of  each  contraction  is  generally  not  long ;  ordinarily  it 
lasts  from  two  to  five  minutes." 

Dr.  Hicks  has  also  stated,2  referring  to  this  method  of  examination  : 
"  If  we  find  a  tumor  changing  in  density  and  hardness,  we  have  an 
assurance  that  it  is  the  uterus."  But  Tarnier  has  called  attention  to 
the  fact  that  a  distended  bladder  gives  the  same  sensation  of  intermittent 
contractions,  and  the  experience  of  others  can  give  confirming  proofs ; 
so,  too,  according  to  Matthews  Duncan,  contractions  quite  as  distinct 
may  be  observed  in  case  of  a  soft  fibroid  of  the  uterus,  and  with  as 
much  change  of  shape  as  a  pregnant  uterus :  the  first  source  of  error 
would,  of  course,  be  readily  avoided  by  the  use  of  the  catheter. 

At  five  mouths  the  walls  of  the  uterus  have  become  so  elastic  and 
depressible,  and  the  foetus  is  sufficiently  developed  to  be  recognized  by 
palpation  if  the  abdominal  wall  be  not  too  thick  ;  in  this  examination 
some  parts  of  the  uterine  globe  are  harder,  more  resisting  than  others 
which  are  elastic,  and  permit  depression.  As  pregnancy  advances  an 
indistinct  fluctuation  may  be  found,  and  if  the  uterus  is  embraced  by 
the  hands  at  its  sides,  by  pressing  these  alternately  the  foetus,  or  parts 
of  it,  may  be  moved  toward  one  and  then  toward  the  other.  This  is 
known  as  abdominal  ballottement. 

Passive  movement  of  the  foetus  may  also  be  made  by  pressing  with 
a  single  hand  upon  some  portion  of  the  uterine  globe  where  there  is  felt 
a  special  resistance,  that  resistance  coming  from  part  of  the  foetus,  and 
the  pressure  forcing  it  momentarily  away. 

Spontaneous  movements  of  the  foetus  are  almost  certain  to  occur 
during  abdominal  palpation ;  when  they  are  being  made  the  hand 
should  be  kept  immobile,  but  closely  applied  to  the  abdominal  wall. 
These  movements  may  be  recognized  as  early  as  the  last  of  the  fifth  or 
the  first  of  the  sixth  month.  They  may  be  general  or  partial ;  in  the 
former  case  the  entire  body  changes  its  position,  and  a  general  change 
in  the  form  of  the  uterus  temporarily  occurs ;  the  movement  is  gradual, 
gliding  or  rolling,  and  is  slow.  The  partial  movements  are  those  of  the 
head  or  of  the  members ;  they  are  quick,  local,  as  if  of  sudden  taps  or 
blows  given  at  a  particular  part  of  the  internal  uterine  wall,  and  causing 
the  uterus  at  that  part  for  an  instant  to  change  its  form. 

1  Transactions  of  the  London  Obstetrical  Society,  vol.  xiii. 

2  Transactions  of  the  International  Medical  Congress,  1881. 


196  PHYSIOLOGY  OF  PREGNANCY. 

Active  movements  of  the  foetus  are  most  frequently  observed  in  the 
morning  after  the  woman's  rest,  at  least  they  are  then  most  pronounced. 
Of  course,  if  the  obstetrician  recognizes  such  movements,  he  has  not 
only  positive  proof  of  pregnancy,  but  also  of  the  fcetus  being  alive. 
But  the  inability  to  perceive  these  movements,  or  their  absence,  is  not 
a  proof  that  the  woman  is  not  pregnant ;  for  the  feebleness  of  the  child, 
or  excess  of  liquor  amnii,  may  cause  this  sign  to  be  absent.  Or,  again, 
contractions  of  the  abdominal  muscles,  or  movements  of  the  intestines, 
may  be  mistaken,  and  have  been  so  mistaken  by  even  celebrated 
observers,  for  movements  of  the  fcetus.  He,  therefore,  will  act  most 
wisely  who  avoids  possibility  of  error  by  repeating  once  or  ofteuer  this 
examination,  and  also  confirms  the  results  obtained  by  touch  by  those 
given  by  sight — that  is,  both  feels  and  sees  the  movements  of  the  foetus. 
It  is,  moreover,  fortunate  that  he  is  not  restricted  in  deciding  as  to 
pregnancy  by  a  single  sign,  but  can  combine  others  with  it. 

In  many  cases  at  the  end  of  the  sixth  or  the  beginning  of  the  seventh 
month  different  parts  of  the  foetus,  as  the  head,  breech,  or  limbs,  may 
be  recognized  by  abdominal  palpation.  Nevertheless  a  tense,  resisting 
abdominal  wall,  or  one  that  is  very  thick,  may  render  this  recognition 
impossible. 

The  late  Dr.  Albert  H.  Smith,1  of  Philadelphia,  advised  in  certain 
cases  the  following  method  of  "external  bimanual  ballottement : " 
The  woman  is  placed  upon  the  edge  of  the  bed  with  her  clothing  re- 
moved from  the  abdomen,  and  then  rolled  upon  her  side ;  so  that  the 
anterior  abdominal  wall  projects  over  the  edge  of  the  bed  ;  then  the 
rotation  of  her  body  is  carried  still  further  until  the  enlarged  uterus 
becomes  so  dependent  that  it  may  be  supported  by  the  hand  placed 
beneath  it,  while  the  other  hand  makes  counter-pressure  upon  the 
opposite  side  of  the  uterine  mass.  Thus  let  the  woman  be  upon  her 
left  side,  the  right  side,  therefore,  being  above,  the  examiner  takes  his 
seat  with  his  face  toward  her  head,  his  left  side  being  toward  the 
pendent  abdominal  mass,  but  about  opposite  the  hips.  The  right  hand 
is  then  passed  far  under  the  uterus  as  it  projects  over  the  bed,  the 
palmar  surface  being  in  contact  with  the  abdominal  integument  and  the 
ulnar  edge  toward  the  iliac  bone.  The  left  hand  is  thus  placed  similarly 
upon  the  right  side  of  the  abdomen,  making  counter- pressure  upon  the 
opposite  side  of  the  uterine  body  so  as  to  grasp  it  between  the  two 
palms.  This  gives  a  full  command  of  the  tumor,  and  enables  the 
examiner  to  appreciate  the  shape  and  density  of  the  mass,  its  fluctuating 
character,  and  the  movement  of  a  separate  body  within  it,  which  can  be 
operated  upon  by  manipulation  and  re-percussion."  Dr.  Smith  further 
stated  that  by  this  method  he  has  been  "  able  to  diagnose  a  pregnancy 
of  six  months  when  the  foetal  heart  was  entirely  inaudible." 

In  another  part  of  this  paper  its  author  said  that  even  at  three 
months  and  a  half  it  is  sometimes  possible,  if  the  uterine  wall  be  thin 
and  soft,  to  feel  the  movements  of  the  child  by  a  finger  pressing  firmly 
upon  the  uterus  posteriorly  to  the  neck,  while  the  other  hand  makes 
counter-pressure  through  the  abdominal  wall  upon  the  anterior  and  the 

i  "  Manual  Examination  in  the  Diagnosis  of  Pregnancy."    A  paper  read  before  the  Philadelphia 
County  Medical  Society. 


THE  SIGNS  AND  DIAGNOSIS  OF  PREGNANCY.  197 

superior  surface  of  the  uterus ;  and  further,  "  by  a  gentle  thrust  of  the 
vaginal  finger  upward,  to  feel  the  receding  and  return  of  a  body  loosely 
floating  in  a  liquid ;"  during  this  abdoraino-vaginal  manipulation  the 
woman  is  lying  upon  her  back. 

OBSTETRIC  AUSCULTATION.  Laennec's  treatise  upon  Mediate  Aus- 
cultation was  published  in  1816,  and  two  years  later  Mayor,  of  Geneva, 
stated  that  upon  applying  the  ear  to  the  abdomen  of  a  pregnant  woman 
the  pulsations  of  the  foetal  heart  could  be  heard,  and  he  thus  made 
known  one  of  the  most  important  discoveries  in  obstetric  science.  Ker- 
garadec,  of  Lausanne,  ignorant  of  Mayor's  priority  in  the  discovery, 
announced  the  same  fact  in  1821.  The  discovery  was  an  accident  to 
each  ;  neither  was  listening  for  what  he  heard  ;  Mayor  listened,  hoping 
to  hear  sounds  caused  by  movements  of  the  foetus,  and  Kergaradec  those 
occurring  in  the  atunial  liquor  from  these  movements. 

Kergaradec,  beside  hearing  the  pulsations  of  the  foetal  heart,  heard 
a  sound  attributed  by  him  to  the  circulation  in  the  placenta,  which  he 
therefore  called  the  placental  souffle.  As  will  be  shown  hereafter,  his 
theory  of  the  origin  of  this  souffle  was  erroneous ;  the  souffle  is  not 
connected  with  the  placental  circulation,  and  therefore  the  name  given 
it  was  incorrect. 

In  addition  to  the  two  sounds  mentioned,  other  sounds  are  discovered 
by  obstetric  auscultation  :  those  caused  by  foetal  movements,  a  cardiac 
souffle,  attributed  to  the  passage  of  blood  through  the  foramen  of  Botal, 
and  a  funic  souffle  j1  but  they  are  of  minor  interest,  and  the  two  sounds 
first  discovered  are  of  chief  importance. 

Obstetric  auscultation  is  usually  abdominal,  but  it  may  be  vaginal ; 
Nauche,  at  the  suggestion  of  Maygrier,  devised  an  instrument  called  the 
metroscope  for  auscultating  through  the  vagina.  The  objections  to 
vaginal  auscultation  are  its  difficulty,  the  unwillingness  of  patients  to 
submit  to  it,  and  when  the  instrument  is  applied  to  the  fundus  of  the 
vagina,  or  in  the  cavity  of  the  uterine  cervix,  great  irritation,  causing 
abortion,  may  be  produced.  Nevertheless  it  has  recently  been  revived 
by  Verardini,  of  Bologna,  who  by  this  means  has  been  quite  successful 
in  diagnosing  early  pregnancies.  Abdominal  auscultation  should  be 
mediate  for  these  reasons  :  The  direct  application  of  the  ear  to  the 
abdomen  is  indelicate;  pressure 'upon  a  great  extent  of  surface,  causing 
bruits  from  muscular  contraction,  is  necessary  ;  it  demands  a  constrained 
position  on  the  part  of  the  observer,  and  it  is  not  possible  thus  to  aus- 
cultate some  parts  of  the  abdomen,  and  the  want  of  cleanliness  on  the 
part  of  some  patients  may  make  it  very  objectionable  to  the  examiner.3 
A  stethoscope  is  less  trying  to  the  patient  and  to  the  doctor  ;  it  permits 
examination  of  parts  that  cannot  be  reached  by  the  unarmed  ear,  and 
the  sounds  heard  through  it  are  better  defined  and  their  limit  better 
determined.  The  stethoscope  should  not  be  less  than  six  inches,  about 
15  centimetres,  long.  The  woman  should  lie  upon  her  back,  with  her 

1  The  funic  souffle,  discovered  by  Kennedy  in  1833,  is  a  blowing  sound  synchronous  with  the 
foetal  heart,  and,  according  to  Winckel,  is  heard  in  three-fourths  of  all  cases.    This  observer  also 
states  that  in  33  per  cent,  of  all  the  cases  in  which  it  is  heard  the  cord  is  abnormally  short,  or  long, 
and  that  in  8  per  cent,  the  children  perish.    The  souud  is,  as  a  rule,  heard  over  the  child's  back, 
and  near  the  heart. 

2  Nevertheless,  if  failure  occur  using  the  stethoscope,  immediate  auscultation  may  be  employed. 


198  PHYSIOLOGY  OF  PREGNANCY. 

limbs  extended  or  only  slightly  flexed.  In  the  course  of  the  examina- 
tion it  may  sometimes  be  necessary  for  her  to  turn  upon  one  or  the  other 
side,  but  the  examination  will  be  made  chiefly  without  change  of  posi- 
tion. In  some  cases,  from  motives  of  delicacy,  the  abdomen  may  be 
kept  covered,  and  a  single  thickness  of  thin  unstarched  material  will 
not,  as  a  rule,  materially  interfere  with  hearing  the  sounds  sought ;  but, 
as  Depaul  advises,  in  all  cases  of  doubt  or  difficulty  the  abdomen  must 
be  naked. 

UTERINE  SOUFFLE.  Upon  applying  the  stethoscope  to  the  abdomen 
of  a  woman  some  five  or  six  months  pregnant,  or  more — according  to 
Spiegelberg,  it  may  be  audible  at  four  months — probably  the  first  sound 
heard  is  that  which  was  originally  called  the  placental  souffle,  and  which 
some  physicians  of  to-day  still  thus  miscall ;  it  is  properly  termed  the 
uterine  souffle.  That  the  placenta  has  nothing  to  do  with  the  production 
of  the  sound  in  question  is  proved  by  the  fact  that  it  may  be  heard  two 
or  three — in  some  cases  five  or  six — days  after  labor.  Since  this  souffle 
may  be  heard  several  days  after  labor,  it  is  plain  that  when  heard  dur- 
ing pregnancy  the  place  at  which  it  is  most  distinct  does  not  indicate 
the  site  of  placental  attachment.  Beside  the  placental  theory  of  this 
sound,  it  has  been  attributed  to  an  impoverished  condition  of  the  blood, 
to  pressure  of  the  gravid  uterus  upon  the  iliac  arteries  and  upon  the 
aorta,  more  recently  by  Glenard  at  first  to  the  circulation  in  the  epi- 
gastric and  then  to  that  in  the  "puerperal"  artery. 

The  theory  of  its  origin  which  is  now  most  generally  accepted  is  that 
of  Dubois,  somewhat  modified  by  Depaul.1  The  sound  is  heard  most 
distinctly  at  the  sides  of  the  uterus  where  the  blood-supply  of  the  organ 
is  received ;  the  arteries  upon  entering  the  uterus  immediately  dilate, 
offering  permanently  a  capacity  which  seems  too  great  for  the  blood 
they  have  to  receive.  This  disproportion,  which  does  not  naturally 
exist  in  other  parts  of  the  organ,  may  nevertheless  be  produced  under 
the  influence  of  different  causes  whose  action  is  transient  and  varying 
from  one  minute  to  another.  Among  these  causes  the  most  common 
are  those  which  result  from  compressions  caused  by  projections  of  dif- 
ferent parts  of  the  foetal  ovoid.  Thus  it  happens,  in  correspondence 
with  these  changes,  there  are  changes  in  the  uterine  souffle  which  may 
be  heard  distinctly  one  minute  at  a  particular  part  of  the  uterus,  and 
then  instantly  cease.  The  sound  is  single,2  without  shock,  is  synchro- 
nous with  the  mother's  pulse,  and  resembles  the  souffle  of  a  varicose 
aneurism ;  it  varies  in  character  and  in  distinctness ;  it  may  be  sibilant, 
or  humming,  or  sonorous ;  it  has  been  compared  to  the  sound  made  by 
saying  in  a  low  tone  voo.  It  is  best  heard  when  the  stethoscope  is  ap- 
plied to  the  lower  lateral  parts  of  the  uterus ;  it  is  usually  first  recognized 
in  the  fifth  month,  but  Depaul  heard  it  in  the  tenth  week,  Spiegelberg 
from  the  eighth  to  the  ninth,  as  did  also  Verardiui. 

From  the  explanation  that  has  been  given  of  the  cause  of  this  sound 
it  can  readily  be  understood  that  whenever  the  uterus  has  a  notably  in- 
creased supply  of  blood  the  uterine  souffle  may  be  heard ;  thus  it  has 

1  Dictionnaire  Encyclopedique  des  Sciences  MMicales. 

2  Winckel  believes  that  the  murmur  is  not  only  intermittent,  but  may  be  continuous ;  in  the 
former  case  being  arterial  and  in  the  latter  venous. 


THE  SIGNS  AND  DIAGNOSIS  OF  PREGNANCY. 


199 


FIG.  105. 


been  found  in  some  cases  of  large  uterine  fibroids.  As  a  sign  of  preg- 
nancy, therefore,  it  has  little  value ;  taken  in  connection  with  others  it 
adds  strength,  but  must  not  be  relied  upon  alone.  Even  if  the  pregnant 
state  be  known,  this  sound  gives  no  information  as  to  the  condition  of 
the  foetus,  for  its  death  makes  no  change  in  the  souffle. 

SOUNDS  OP  THE  FCETAL,  HEART.  These  sounds  have  been  very 
generally  compared  to  the  tic-tac  of  a  watch  put  under  a  pillow  upon 
which  the  ear  is  placed.  The  first  sound  is  the  more  distinct,  and  corre- 
sponds with  the  pulsation  in  the  umbilical  arteries;  the  interval  between 
the  two  sounds  is  less  than  that  between  the  double  pulsations,  or,  as 
one  may  say,  it  is  twice  as  long  between  a  tac  and  a  tie  as  it  is  between 
a  tic  and  a  lac,  and  this  difference  may  be  thus  expressed,  tic-tac — tic-tac. 

Depaul  in  several  cases  heard  these  sounds  at  three  months  and  a  half, 
and  in  one  at  the  latter  part  of  the  third  month.1  "  At  the  end  of  the 
fourth  month  the  cases  in  which  auscultation  is  uselessly  practised  are 
much  more  rare,  and  they  become  so  much  more  exceptional  as  women 
are  nearer  the  term."  In  906  pregnant  women  examined  by  Depaul, 
the  sound  of  the  foetal  heart  failed  to  be 
heard  but  eight  times,  and  some  of  these 
failures,  he  states,  are  to  be  attributed  to 
another  cause  than  the  powerlessness  of 
auscultation. 

In  listening  for  these  sounds  the  stetho- 
scope should  be  applied  up  to  four  months 
to  the  fuudus  of  the  uterus,  and  in  a  line 
corresponding  with  the  axis  of  the  inlet. 
With  the  ascension  of  the  uterus  in  the 
abdominal  cavity  the  instrument  must 
usually  be  placed  upon  one  or  the  other 
side,  though  sometimes  the  sounds  are 
more  distinct  in  the  median  line.  Dur- 
ing the  last  three  months  of  pregnancy 
the  sounds  are,  in  the  great  majority  of 
cases,  most  distinctly  heard  at  the  middle 
of  a  line  drawn  from  the  umbilicus  to  the 
left  anterior  superior  spinous-  process ; 
failing  to  hear  them  here,  the  physician 
should  next  listen  at  a  corresponding 
point  upon  the  right  side ;  if  the  sounds 
cannot  be  heard  at  either  of  these  points, 
the  stethoscope  should  be  applied  above 
the  umbilicus,  upon  one,  then,  if  necessary, 
upon  the  other  side  of  the  median  line. 

The  following  illustration,  from  Depaul's 
.-,,.    .          _.     »     .      ,       ,  ,.,£  DIFFERENT  PARTS  OF  ABDOMEN  FOR 

(Jlmique  Obstetncale,  shows  these  different  AUSCULTATION. 

points.     The  examiner  first  applies  his 

stethoscope  at  D ;  if  he  fails  to  hear  the  sounds  at  this  point,  or  hears 

them  only  indistinctly,  he  next  listens  at  C ;  finally,  he  tries  the  points 


Depaul,  op.  cit. 


200  PHYSIOLOGY  OF  PREGNANCY. 

A  and  B,  if  no  satisfactory  result  has  been  obtained  by  auscultating  at 
DorC. 

.  The  pulsations  of  the  foetal  are  much  more  frequent  than  those  of  the 
maternal  heart,  and  vary  from  120  to  160  a  minute,  the  mean  being  140 ; 
these  pulsations  vary  in  the  same  foetus  as  to  frequency,  becoming  slower 
or  faster  from  one  time  to  another.  The  distinctness  with  which  they 
are  heard  will  of  course  depend  upon  the  size  and  development  of  the 
foetus,  and  upon  its  position,  upon  the  quantity  of  liquor  amnii,  and  the 
thickness  of  the  uterine  and  of  the  abdominal  walls.  The  frequency  of 
the  pulsations  is  uninfluenced  by  the  mother's  circulation,  but  it  is  by 
her  temperature,  increasing  as  that  increases. 

Important  movements  of  the  foetus,  whether  spontaneous  or  resulting 
from  external  causes,  are  followed  by  an  acceleration  of  the  pulsations, 
while  these  become  slower  at  the  height  of  a  uterine  contraction.'  Ex- 
ceptionally, Kaltenbach  states,  the  impulse  of  the  heart  is  palpable. 

OTHER  SOUNDS  HEARD  IN  ABDOMINAL  AUSCULTATION  IN  PREG- 
NANCY. Olshausen  attaches  much  importance  to  the  recognition  by  the 
ear  of  foetal  movements,  stating  that  they  may  be  heard  in  the  latter 
part  of  the  fourth  month,  and  therefore  usually  before  the  sounds  of  the 
heart  are  audible. 

FCETAL  SHOCK,  CHOC  FCETAL  OF  PAJOT.  Toward  the  end  of  the 
first  half  of  pregnancy v  if  the  stethoscope  is  applied  to  the  abdomen, 
pressing  but  gently,  the  examiner  perceives  a  double  sensation  of  slight 
shock  and  a  bruit  from  a  movement  of  the  foetus.  Pajot  claims  that 
this  sign,  thus  addressing  general  and  special  sensibility,  is  more  readily 
recognized  in  the  existing  period  of  development  than  are  the  sounds 
of  the  foetal  heart,  and  in  many  cases  are  heard  earlier. 

FUNIC  SOUFFLE.  The  funic  souffle,  discovered  by  Kennedy  in 
1833,  is  a  blowing  sound  synchronous  with  the  foetal  heart.  Winckel 
states  that  it  can  be  heard  in  three-fourths  of  all  cases.  In  33  per  cent, 
of  cases  the  cord  was  unusually  short,  or  abnormally  long ;  it  is  heard 
ten  times  as  frequently  in  velamentous  insertion  ;  tension,  pressure,  and 
displacement  are  its  chief  causes.  Ettinger's  conclusion1  is  that  the 
funic  souffle  is  caused  by  compression  of  the  vessels,  chiefly  from  coils, 
true  knots,  or  shortness  of  the  cord. 

Runge  remarks  that  in  very  rare  cases  congenital  valvular  defects  of 
the  heart  may  manifest  their  existence  in  pregnancy,  continuing  during 
it,  and  also  audible  after  birth,  producing  a  sound  similar  to  the  funic 
souffle. 

PREDICTION  OF  SEX.  It  has  been  held  that  there  is  a  relation 
between  the  frequency  of  the  pulsations  and  the  sex  of  the  foetus — 
Frankenhauser,  and  others — while  Gumming  maintained  that  this  fre- 
quency depended  upon  the  weight  of  the  child.  Danzats  states  that  if 
the  pulsations  are  more  than  145  a  minute  the  probability  is  in  favor 
of  the  child  being  a  female,  under  135  a  male,  and  between  these  num- 
bers a  prediction  cannot  be  made.  Hennig  and  Ziegenspeck  found  the 
average  frequency  of  the  pulsation  of  the  heart  of  the  male  foetus  136, 
and  that  of  the  female  139 ;  this  difference  is  so  small  that,  as  Winckel 

1  Inaugural  Dissertation,  Zurich,  1888. 


THE  SIGNS  AND  DIAGNOSIS  OF  PREGNANCY.  201 

remarks,  it  is  seldom  possible  to  predict  the  sex,  and  this  expresses  the 
general  opinion  of  the  profession.  Some,  however,  differ.  In  this  coun- 
try Professor  Frank  C.  Wilson,  of  Louisville,  Ky.,  has  for  some  years 
given  much  attention  to  the  subject,  and  his  conclusions  are  here  pre- 
sented. 

LOUISVILLE,  Ky.,  July  14,  1884. 
PROF.  TH.  PARVIN, 

^DEAR  DOCTOR  :  In  reply  to  yours  of  10th  inst.  I  would  say  that  with  a  rea- 
sonable degree  of  accuracy  the  sex  may  be  predicted  from  the  rapidity  of  the 
foetal  heart  sounds.  These  vary  from  110  to  170  per  minute,  and  134  may  be 
taken  as  the  dividing-line,  above  which  the  sex  will  be  female,  and  below  which 
the  sex  will  be  male,  the  certainty  increasing  the  further  you  recede  from  the 
dividing-point.  The  following  rules  I  have  found  useful  in  determining  the  sex : 

From  110  to  125  the  sex  will  be,  almost  certainly  male 
125  to  130       "  "       probably  male. 

130  to  134       "          "       doubtful  with  chances  in  favor  of  male. 
134  to  138       "          "  "          "          "  "          female. 

138  to  143       "  "       probably  female. 

143  to  170       "  "       almost  certainly  female. 

Although  failures  occasionally  occur,  they  are  not  numerous. 

Very  sincerely  yours, 

FRANK  C.  WILSON. 

Certainly,  in  view  of  the  statements  of  Dr.  Wilson,  who  is  one  of  the 
most  careful,  competent,  and  conscientious  observers,  the  subject  is  de- 
serving of  further  investigation. 

My  young  friend,  Dr.  Charles  H.  Reckefus,  has  recently  been  giving 
considerable  attention  to  the  study  of  the  possibility  of  predicting  the 
sex  from  the  rate  of  the  pulsations  of  the  foatal  heart,  and  in  February  of 
this  year,  1895,  he  has  furnished  me  the  following  statement :  "  Using 
134  as  the  dividing-line,  I  found  out  of  66  cases  the  prediction  as  to  sex 
correct  in  49  instances,  incorrect  in  17. m 

1  Dr.  Ross,  of  Belfast,  makes  the  following  statement  in  the  British  Medical  Journal,  July,  1891 : 
"  If  I  find  the  mother  describes  the  foetal  movements  are  felt  chiefly  and  most  distinctly  on  the  left 
side,  I  emphatically  predict  a  male  birth :  if  on  the  right,  I  as  surely  determine  the  sex  to  be 
female." 


CHAPTER    VIII. 

THE  DIAGNOSIS  OF  PLURAL  PREGNANCY — DIFFERENTIAL  DIAG- 
NOSIS OF  PREGNANCY — DIAGNOSIS  OF  PREVIOUS  PREGNANCY,  OF 
PERIOD  OF  PREGNANCY — DURATION  OF  PREGNANCY — DATE  OF 
LABOR — PRECOCIOUS  BIRTHS — PROLONGED  PREGNANCY — MISSED 
LABOR. 

DIAGNOSIS  OF  TWIN  PREGNANCY.  In  the  great  majority  of  cases 
this  is  not  made  until  after  the  birth  of  the  first  child ;  indeed,  Capuron1 
thought  that  certain  proof  could  only  then  be  had  ;  in  this,  however,  he 
was  mistaken,  as  will  be  hereafter  shown.  Yet  the  diagnosis  is  by  no 
means  always  readily  made,  and  in  most  cases  the  obstetrician  must  be 
content  with  a  probability  instead  of  attaining  a  certainty. 

The  signs  of  a  plural  pregnancy2  are  conveniently  divided  into  prob- 
able and  certain.  Among  the  former  are  extraordinary  enlargement  of 
the  abdomen,  the  size  being  greater  than  in  correspondence  with  the 
period  of  pregnancy ;  unusual  form  of  the  abdominal  prominence,  the 
uterus  being  developed  more  in  its  transverse  than  in  its  vertical  diam- 
eter ;  lateral  is  more  marked  than  median  projection,  so  that  in  some 
cases,  as  Mauriceau  stated,  there  is  a  depression  directly  in  the  median 
line,  and  "  an  eminence  on  each  side  of  the  abdomen ; "  foetal  move- 
ments observed  at  different  parts  of  the  abdomen,  these  movements 
being  more  frequent  and  stronger  than  usual ;  and  finally,  the  disorders 
of  pregnancy  are  more  decided  than  when  only  one  foatus  is  present ; 
there  is  also  greater  liability  to  premature  labor. 

The  venous  circulation  is  seriously  interfered  with  by  the  great  de- 
velopment of  the  abdomen,  and  hence  oedema  of  the  lower  limbs  and  of 
the  abdominal  walls.  Depaul  attached  some  importance  to  an  cedema- 
tous  swelling,  triangular  in  form,  having  its  base  at  the  pubes,  and  its 
apex  pointing  toward  the  umbilicus,  as  indicative  of  a  plural  pregnancy. 

DIAGNOSIS  BY  PALPATION.  The  certain  signs  of  plural  pregnancy 
are  given  by  vaginal  touch,  abdominal  palpation,  and  by  auscultation. 
Vaginal  touch  may,  after  labor  has  begun,  furnish  the  evidence  of  a 
twin  pregnancy ;  thus,  it  is  possible  there  may  be  recognized,  as  was 
done  by  Depaul  in  two  cases,  a  furrow  dividing  the  protruding  bag  of 
waters  into  two  parts,  indicating  the  presence  of  two  foetal  sacs ;  Char- 
pentier  states  this  sign  was  first  made  known  by  Duges  and  Madame 
Lachapelle.  The  cases  are  rare  in  which  it  is  present.  In  consequence 
of  the  relatively  less  quantity  of  liquor  amnii,  and  of  the  fact  that  the 
uterine  cavity  is  so  largely  occupied  by  the  foetuses,  passive  movements 

1  When  almost  eighty  years  of  ace,  and  after  having  been  a  teacher  of  obstetrics  for  nearly  fifty 
years,  he  one  day  said  to  Pajot:  "  My  friend,  there  is  but  one  way  by  which  you  may  certainly 
know  a  twin  pregnancy.    If  you  have  seen  one  fcetus  born,  and  find  there  is  another  in  the  uterus, 
you  may  be  sure  there  are  twins." 

2  Mr.  Rigby,  at  the  age  of  eighty,  was  the  father  of  four  children  at  one  birth.     Gooch's  Com- 
pendium. 


DIFFERENTIAL  DIAGNOSIS  OF  PREGNANCY.  203 

of  these,  or  abdominal  ballottement,  cannot  be  so  readily  made ;  and, 
on  the  other  hand,  if  the  very  great  uterine  enlargement  be  caused  by 
polyhydramnios,  the  mobility  of  the  foetuses  is  greater  than  is  normally 
present.  Again,  there  is,  as  expressed  by  Pinard,  a  permanent  tension 
of  the  uterine  wall  in  case  of  plural  pregnancy.  "This  wall,  instead 
of  being  easily  depressed,  is  tense  and  resisting;  it  gives  a  sensation 
similar  to  that  caused  by  pressing  upon  a  rubber  bag  distended  by  air 
or  by  a  liquid."  Next  the  presence  of  fcetal  members  in  different  parts 
of  the  uterus  may  be  sought,  and  then  the  two  foetal  poles  in  the  upper 
and  two  also  in  the  lower  portion  of  the  uterus  conclude  the  diagnosis 
of  twin  pregnancy  by  palpation.  By  this  means  Pinard  discovered  in 
thirty-two  cases  the  presence  of  twins  in  the  uterus.  He  also  diagnosed 
triplets  between  the  fifth  and  sixth  month  of  pregnancy ;  he  found 
three  heads,  one  in  the  pelvic  cavity,  a  second  in  the  right  iliac  fossa, 
and  a  third  above  and  near  the  median  line. 

It  is  well  not  to  entertain  too  great  confidence  in  this  method  of  diagnosis,  and 
therefore  not  to  be  disappointed  by  at  least  occasional  failures  ;  indeed,  Depaul 
regarded  it  as  only  exceptionally  possible,  as  the  following  passage  indicates : 
"  Some  practitioners  in  fact  teach  that  one  can  distinguish  through  the  abdom- 
inal walls  two  foetuses.  The  necessary  conditions  for  such  a  diagnosis  are  only 
very  exceptionally  presented,  for  in  multiple  pregnancy  the  uterine  and  abdom- 
inal walls  are  usually  tense,  and  can  only  with  pain  and  difficulty  be  depressed 
by  the  hand  of  the  examiner.  Besides,  it  is  much  less  easy  than  is  generally 
thought  to  distinguish  the  different  regions  of  the  foetus  through  the  abdominal 
and  uterine  walls,  and  when  you  wish  to  apply  palpation  to  the  diagnosis  of  pre- 
sentations of  the  shoulder  and  of  the  pelvic  extremity  you  will  recognize  how 
much  the  hips,  by  their  roundness  and  resistance,  offer,  through  the  walls  which 
separate  them  from  the  hand,  resemblance  to  the  cephalic  extremity." 

DIAGNOSIS  BY  AUSCULTATION.  Kergaradec  was  the  first  to  point 
out  the  possibility  of  recognizing  a  twin  pregnancy  by  hearing  the 
sounds  of  two  fcetal  hearts.  Subsequently,  however,  others  regarded 
the  supposed  placental  bruit  as  giving  this  proof,  for  indeed,  according 
to  the  original  theory  as  to  the  origin  of  this  sound,  it  would  be  heard 
at  two  different  points  corresponding  with  the  situations  of  the  two 
placentae.  But  this  view,  according  to  which  the  sound  .referred  to 
resulted  from  the  circulation  in  the  utero-placental  vessels,  being,  as 
has  been  previously  shown,  an  error,  of  course  a  correct  diagnosis  could 
not  be  founded  upon  it.  We  return,  therefore,  to  the  original  sugges- 
tion of  Kergaradec,  and  find  that  the  "  double  pulsations  of  the  fcetal 
heart,  heard  at  two  different  points  of  the  uterus,  with  a  maximum 
of  intensity  and  without  isochronism,  show  the  presence  of  two  foetuses 
in  the  uterine  cavity."  In  making  this  examination  care  should  be 
taken  to  exclude  any  error  which  would  arise  from  confounding  the 
sounds  of  the  mother's  heart  with  those  of  a  fcetal  heart.  In  order 
that  the  diagnosis  of  twins  can  be  correctly  made  by  auscultation,  the 
obstetrician  must  hear  fcetal  heart-sounds  most  clearly  at  different 
parts  of  the  uterus,  in  neither  case  isochronous  with  the  mother's  pulse, 
nor  isochronous  with  each  other.  The  variation  in  frequency  be- 
tween the  heart-sounds  of  two  foetuses  may  be  only  six  or  eight,  or 

1  Lejons  de  Clinique  Obstetricale. 


204  PHYSIOLOGY  OF  PREGNANCY. 

it  may  be  fifteen  or  sixteen,  but  there  is  always  a  notable  difference- 
It  must  be  borne  in  mind  that  the  comparative  results  must  be,  in 
each  case,  those  obtained  at  the  same  examination,  for  the  frequency 
of  the  sounds  of  the  foetal  heart  varies  from  one  time  to  another. 
Usually  the  maximum  of  intensity  of  the  heart-sounds  of  one  foetus  is 
found  higher  than  that  of  the  other,  nor  are  the  two  maxima  upon 
the  same  side  of  the  median  line.  For  example,  referring  to  Fig.  105, 
one  maximum  might  be  heard  at  D,  and  the  other  at  A  or  at  C.  The 
conclusion  as  to  multiple  pregnancy  should  not  be  drawn  from  a  single 
examination,  lest  an  error  may  arise  from  change  of  position  of  the 
foetus,  in  case  of  single  pregnancy,  or  from  change  in  the  frequency  of 
its  heart-sounds.  Of  course,  an  error  might  occur  in  case  there  were 
more  than  two  foetuses  in  the  uterus,  but  the  contingency  of  triplets 
even  is  so  small  that  mistakes  thence  resulting  will  be  very  rare.  In  a 
case  of  triplets,  H.  F.  Naegele,  by  auscultation  during  pregnancy,  di- 
agnosed twins ;  when  labor  occurred,  and  after  one  of  the  children  had 
been  born,  he,  by  the  same  means,  discovered  that  there  were  still  two 
foetuses  in  the  uterus,  and  then  made  the  diagnosis  of  triplets. 

Even  if  the  practitioner,  after  careful  examination,  is  positive  of  a 
plural  pregnancy,  it  is  not  wise  in  most  cases  to  let  the  woman  know 
his  discovery,  for  to  some  the  fact  would  be  a  source  of  fear  and  anxiety 
as  to  the  labor,  and  to  others,  of  care  and  worry  as  to  the  double  burden 
which  would  be  imposed  upon  them  after  the  birth  of  the  children. 
Of  course,  auscultation  will  be  without  value  in  the  diagnosis  of  plural 
pregnancy  if  one  of  the  foetuses  be  dead,  but  palpation  might  then  be 
of  use.  It  is  better,  however,  especially  for  the  young  practitioner,  not 
to  depend  exclusively  upon  either  mode  of  examination,  but  rather  com- 
bine them,  modifying  the  results  obtained  by  one  with  those  derived 
from  the  other. 

DIFFERENTIAL  DIAGNOSIS  OF  PREGNANCY.  Certain  pathological 
conditions  may  be  mistaken  for  pregnancy,  and  the  chief  of  these,  with 
the  means  by  which  error  as  to  their  character  may  be  avoided,  will  now 
be  given. 

First.  Affections  which  Increase  the  Size  of  the  Uterus. 

PHYSOMETRA.  Gas  may  be  formed  in  the  uterus  from  decomposi- 
tion of  retained  secretions  or  of  fragments  of  an  ovum.  This  gas  may 
be  retained  if  there  be  acquired  atresia,  or  it  may  be  discharged  from 
time  to  time  in  case  there  be  only  stenosis.  When  stenosis  and  dis- 
charges of  gas  occurred  Gooch  called  the  condition  flatus  of  the  uterus. 
Of  course,  there  is  little  danger  of  confounding  a  case  of  either  form  of 
the  disorder  with  pregnancy.  The  uterus  is  but  slowly  and  slightly 
increased  in  size ;  if  it  be  large  enough  for  percussion  to  be  made,  the 
tympanitic  sound  evoked  points  to  the  nature  of  the  enlargement,  and 
at  the  same  time  palpation  and  auscultation  give  negative  results. 

HYDROMETRA.  A  collection  of  watery  fluid  may  take  place  in  the 
uterus  when  the  os  is  occluded.  Usually  the  uterus  is  no  larger  than 
an  orange,  and  the  increase  of  size  is  slow ;  it  generally  occurs  in  women 
who  have  passed  the  childbeariug  period,  though  Voisin  met  with  it 
in  a  patient  only  forty  years  of  age.  .  Schroder  has  mentioned  a  case  of 
its  occurrence  in  a  woman  in  consequence  of  cervical  atresia  caused  by 


DIFFERENTIAL  DIAGNOSIS  OF  PREGNANCY.  205 

the  application  of  the  actual  cautery  for  sarcoma.  ID  hydrometra,  too, 
the  development  of  the  uterine  tumor  is  slower  than  in  pregnancy,  and 
the  other  usual  signs  of  this  condition  are  absent.  Both  physometra 
and  hydrometra  are  rare. 

H^EMATOMETRA.  Accumulation  of  menstrual  blood  in  the  uterus 
has  given  rise  to  some  most  deplorable  errors  of  diagnosis,  errors  that, 
however,  can  be  readily  avoided  by  a  careful  study  of  the  history  of  the 
enlargement,  followed  by  a  suitable  examination.  Such  an  accumula- 
tion results  from  either  congenital  or  acquired  atresia  of  some  part  of 
the  genital  canal,  and  of  course  this  atresia  can  be  readily  ascertained 
by  a  direct  examination.  The  history  of  the  enlargement  is  that  it  has 
lasted  longer  than  pregnancy  does,  that  it  has  taken  place  abruptly  from 
time  to  time,  increasing  periodically  instead  of  continuously ;  the  periods 
of  abrupt  increase,  as  a  rule  attended  with  more  or  less  severe  suffering, 
usually  occurred  once  in  each  month.  Upon  palpation  the  uterus  is 
found  tense  and  resisting,  not  yielding  and  elastic  as  it  ordinarily  is  in 
pregnancy;  no  foetal  parts  can  be  felt,  and  auscultation  is  negative. 

UTERINE  FIBROIDS.  The  uterus  is  in  most  cases  irregular  in  form, 
and  is  hard  and  resisting,  instead  of  elastic  and  yielding.  Instead  of 
menstruation  being  absent,  as  is  the  fact  in  pregnancy,  it  is  usually 
irregular  and  profuse ;  the  mammary  signs  of  pregnancy  are  as  a 
rule  absent,  and  the  umbilicus  does  not  show  the  changes  which  occur 
in  the  pregnant  woman.  The  sympathetic  disturbances  of  the  early 
months  of  gestation  have  not  been  observed,  and  the  growth  has  been 
much  slower  than  the  physiological  development  of  the  uterus;  the 
cervix  does  not  present  the  changes  characteristic  of  pregnancy.  The 
uterine  souffle  may  be  present,  but  the  sounds  of  the  foetal  heart  are 
absent. 

INCREASE  IN  SIZE  OF  ABDOMEN  WITHOUT  CHANGE  IN  SIZE  OF 
UTERUS — OVARIAN  TUMORS.  Among  the  means  that  may  be  avail- 
able in  distinguishing  these  growths  from  pregnancy  are  the  presence 
of  menstruation,  and  the  enlargement  having  been  first  observed  upon 
one  or  the  other  side  instead  of  in  the  median  line,  and  its  development 
being  slower  than  that  of  pregnancy.  But  amenorrhoaa  is  found  in 
quite  a  number  of  patients  suffering  with  cystic  ovarian  disease  either  if 
they  have  become  anaemic,  or  iriternal  hemorrhage  has  occurred ;  as  to 
the  place  of  origin  of  the  enlargement,  unfortunately  many  patients 
observe  badly  or  forget  readily,  so  that  this  help  often  fails,  and  while 
usually  the  enlargement  of  pregnancy  is  more  rapid  than  that  of  an 
ovarian  tumor,  exceptions  to  the  rule  may  occur. 

The  deterioration  of  health  and  the  emaciation,  especially  noticeable 
in  the  face,  will  be  marked  if  the  tumor  has  attained  great  size.  The 
fluctuation  is  usually  distinct  in  cystic  disease  of  the  ovary,  absent  or 
very  obscure  in  normal  pregnancy  ;  in  polyhydramnios  the  fluctuation 
is  quite  marked,  but  it  is  especially  at  the  upper  part  of  the  abdomen, 
while  in  ovarian  dropsy  the  fluctuation  is  commonly  more  general. 
The  results  of  touch  and  auscultation  are  negative,  and  the  reflex  dis- 
turbances of  pregnancy  are  generally  absent.  Nevertheless,  there  are 
some  cases  in  which  a  positive  diagnosis  should  not  be  given  at  once; 
delay  and  repeated  examinations  may  be  necessary  to  avoid  a  mistake. 


206  PHYSIOLOGY  OF  PREGNANCY. 

ASCITES.  It  seems  strange,  nevertheless  it  is  true,  that  the  abdomen 
enlarged  by  ascitic  effusion  has  been  mistaken  for  the  enlargement  of 
pregnancy.  The  shape  of  the  former  is  different  from  that  of  the  latter, 
and  fluctuation  is  always  distinctly  and  everywhere  present,  whereas  in 
pregnancy  fluctuation  is  not  distinct  except  in  polyhydramnios,  and 
then  chiefly  discovered  in  the  upper  part  of  the  uterus.  In  ascites  the 
uterus  is  unchanged  in  form,  size,  and  position  ;  the  menstrual  function 
may  be  regularly  exercised,  and  the  reflex  disturbances  of  pregnancy 
are  absent.  The  disease  has  in  most  cases  an  obvious  cause  in  some 
affection  of  the  liver,  kidneys,  or  heart.  Palpation  and  auscultation 
give  negative  results  as  to  pregnancy. 

ACCUMULATION  OF  FAT  IN  THE  ABDOMINAL  WALL  OR  IN  THE 
OMENTUM.  Such  an  increase  of  size  is  more  frequently  observed  in 
women  from  forty  to  fifty  years  of  age  than  at  any  other  time  of  life. 
The  abdominal  wall  becomes  not  only  prominent  but  pendent,  and  the 
woman  has,  as  Dr.  Bailie  expressed  it,  a  double  chin  in  the  belly.  In 
such  a  subject  it  is  generally  easy,  if  she  be  lying  down,  for  the  phy- 
sician, placing  a  hand  on  each  side  of  the  abdomen,  to  include  between 
them  the  entire  mass,  and  partially  lift  it  up,  thus  determining  its  true 
character.  There  is  entire  absence  of  the  signs  of  pregnancy  furnished 
by  auscultation  and  touch.1 

PSEUDO-CYESIS,  OR  FALSE  PREGNANCY.  False,  or  nervous,  preg- 
nancy generally  occurs  in  women  who  have  married  late  in  life,  and 
who  are  anxious  for  offspring,  or  who  wish  to  give  proof  of  their  still 
having  the  power  of  reproduction.  They  frequently  present  many  of 
the  subjective  and  some  of  the  objective  signs  of  pregnancy,  the  intense 
desire  to  be  pregnant  begetting  many  of  the  evidences  of  the  condition. 
In  some  of  these  subjects  abdominal  enlargement  may  be  observed  ; 
menstruation  may  be  absent,  or  scanty  and  irregular ;  the  breasts  may 
increase  in  size  and  contain  milk  ;  the  stomach  may  be  irritable ;  and, 
finally,  the  woman  is  usually  positive  that  she  feels  foetal  movements. 
The  climax  of  the  delusion  of  spurious  pregnancy  may  be  spurious 
labor.  The  etiology  of  these  cases  is  obscure.  The  women  are  honest 
in  their  belief,  they  do  not  desire  to  deceive  others,  but  they  are  them- 
selves deceived.  Nor  can  this  self-deception  and  the  phenomena  of 
false  pregnancy  and  labor  be  accounted  for  by  the  action  of  the 
imagination,  for  similar  phenomena  have  been  observed  in  some  of  the 
inferior  animals. 

Over-fed  bitches,  which  admit  the  dog  without  fecundation  following,  are 
nevertheless  observed  to  be  sluggish  about  the  time  they  should  have  whelped, 
and  to  bark  as  they  do  when  their  time  is  at  hand,  also  to  steal  away  the  whelps 
from  another  bitch,  to  tend  and  lick  them,  and  also  to  fight  fiercely  for  them. 
Others  have  milk  or  colostrum,  as  it  is  called,  in  their  teats,  and  are  moreover 
subject  to  the  diseases  of  those  who  have  actually  whelped.  (Harvey  On  Con- 
ception.) 

Professor  Haughton  reported  to  the  Dublin  Obstetrical  Society  (February  7, 
1880)  an  interesting  case  of  phantom  tumor  observed  in  an  ass  that  had  been 
covered  by  a  zebra ;  the  appearance  of  pregnancy  deceived  an  expert. 

1  If  the  obesity  is  rapid  in  its  development,  if  there  are  abdominal  striae,  and  amenorrhoea  is 
present,  the  liability  to  error  is  increased.  Such  a  case  recently  came  to  my  knowledge,  and  the 
diagnosis  of  pregnancy  having  been  made,  and  false  labor  coming  on,  Csesarean  section  was  done 
— the  patient  had  a  deformed  pelvis — and  the  increase  in  size  was  proved  to  be  solely  from  deposit 
of  fat  in  the  abdominal  wall. 


DIAGNOSIS  OF  PREVIOUS  PREGNANCY.  207 

In  the  diagnosis  of  pseudo-cyesis  the  physician  must  give  little  or  no 
weight  to  the  subjective  signs  of  pregnancy,  or  he  will  almost  certainly 
be  misled.  Let  him,  therefore,  if  the  alleged  pregnancy  be  far  enough 
advanced  to  make  the  objective  signs  available,  trust  to  them,  and  in 
the  contrary  condition  wait  until  they  ought  to  be  plainly  present  in  a 
case  of  true  pregnancy.  Usually  these  patients,  as  has  been  frequently 
observed,  do  not  send  for  the  physician  until  they  have  been,  as  they 
think,  pregnant  for  several  months,  and  then  they  do  not  ask  for  a 
diagnosis — that  they  have  made  for  themselves — but  for  the  relief  of 
some  temporary  indisposition,  or  to  attend  them  in  their  approaching 
labor.  To  undeceive  such  a  one,  proving  that  her  hopes  are  false,  is 
generally  a  thankless  and  difficult  task  ;  it  ought  not  to  be  attempted 
without  first  having  conclusive  evidence  obtained  by  touch  and  auscul- 
tation. 

PATHOLOGICAL  CONDITIONS  RENDERING  THE  DIAGNOSIS  DIFFI- 
CULT. In  case  of  pregnancy  occurring  in  a  woman  suffering  from  an 
abdominal  enlargement  the  former  is  liable  to  be  overlooked,  the 
pathological  condition  only  being  recognized.  In  some  cases  it  is  pos- 
sible to  remove  the  cause  or  condition  hiding  the  pregnancy,  and  then 
the  latter  will  be  discovered.  Thus,  if  ascites  be  present,  after 
paracentesis  the  proofs  of  pregnancy  may  become  evident.  But  the 
chief  means  to  avoid  error  from  these  sources  are  repeated  examinations 
and  waiting  until  the  signs  of  pregnancy  become  unequivocal.  Pajot, 
in  referring  to  such  difficulties,  remarks  that  there  is  one  distinct 
characteristic  of  the  gravid  uterus  by  which  it  may  be  known  from 
ascites,  fibroids,  hsematometra,  ovarian  cysts,  etc.,  that  is,  that  it,  in  the 
last  third  of  pregnancy,  is  the  only  abdominal  tumor  in  which  there  is 
found  a  mobile  solid  body  in  a  liquid. 

The  obstetrician  should  bear  in  mind  that  abnormal  pregnancy,  e.  g., 
ectopic  gestation,  cystic  disease  of  the  ovum,  or  polyhydramnios,  will 
often  present  peculiar  difficulty  in  diagnosis. 

DIAGNOSIS  OF  PREVIOUS  PREGNANCY.  In  some  cases  it  is  impor- 
tant to  know  whether  a  woman  is  pregnant  for  the  first  time,  or 
whether  she  has  been  pregnant  before,  the  pregnancy  not  ending  in 
abortion.  In  the  primigravida  the  abdominal  wall  is  smooth,  tense, 
and  resisting  and  cannot  be  readily  depressed ;  the  uterus  is  more 
strictly  confined  to  the  vicinity  of  the  median  line,  and  especially  does 
not  incline  anteriorly  so  much  as  it  does  in  the  multigravida.  In  the 
later  part  of  pregnancy  the  stria  usually  found  upon  the  skin  of  the 
abdomen  are  not  white  or  pearl -colored,  but  pink  or  purplish.  The 
mammary  glands  are  round,  full,  prominent,  firm,  not  relaxed,  flabby, 
and  pendent.  The  vulval  orifice  is  small,  closed,  the  posterior  com- 
missure complete,  the  hymen  may  be  torn,  but  the  carunculae  myrti- 
formes  are  absent.  The  vagina  is  comparatively  small,  and  the  rugae 
are  distinct,  prominent,  and  in  intimate  contact  by  the  close  apposition 
of  the  anterior  and  posterior  vaginal  walls.  The  neck  of  the  uterus 
is  conical,  its  orifice,  which  is  closed,  presenting  a  uniform  rim  or 
border. 

In  the  multigravida  the  abdominal  wall  is  relaxed,  not  tense  and  re- 
sisting ;  possibly  separation  of  the  recti  muscles  is  present,  the  striae, 


208  PHYSIOLOGY  OF  PREGNANCY. 

pearl -colored,  of  a  former  pregnancy  may  be  present,  and  possibly,  too, 
with  them  there  may  be  seen  the  purplish  striae  of  the  present  gestation ; 
a  thinned  abdominal  wall  permits  more  readily  palpation  of  the  uterus. 
The  breasts  are  less  firm,  the  glandular  portion  can  be  defined ;  they  usu- 
ally are  somewhat  pendent,  and  in  many  cases  they  are  marked  by  old 
stria3.  The  vaginal  entrance  is  partially  open,  the  labia  rnajora  relaxed, 
pigment  deposit  is  observed,  and  frequently  there  are  varicose  veins.  The 
hymen  has  given  place  to  the  carunculse  myrtiformes,  the  presence  of 
cicatricial  tissue  at  the  perineum  is  not  uncommon.  The  vagina  is  wide, 
relaxed,  its  surface  much  smoother  than  is  that  of  the  primigravida,  and 
either  the  anterior  or  posterior  wall  may  project  into  the  canal.  The 
vaginal  portion  of  the  cervix  is  club-shaped  or  cylindrical,  and  the  os 
uteri  is  usually  split,  so  that  an  anterior  and  posterior  lip  are  distinctly  de- 
fined. In  very  rare  cases  this  physiological  tear  of  the  os  has  not  occurred, 
so  that  to  the  touch  it  presents  the  character  observed  in  the  virgin  or 
of  a  woman  for  the  first  time  in  gestation.  Again,  tearing  of  the  cervix 
may  be  caused  by  the  extraction  of  a  large  fibrous  tumor  from  the  uterus. 
The  possibility  of  error  from  either  of  these  causes  should  be  borne  in 
mind.  Admitting  that  the  woman  has  been  previously  pregnant,  the 
pregnancy  may  have  ended  in  a  miscarriage,  and  then,  of  course,  the 
diagnosis  from  physical  examination  may  fail.  So  too,  if  a  completed 
pregnancy  occurred  some  years  before,  .there  may  sometimes  be  difficulty 
in  the  diagnosis. 

DIAGNOSIS  OF  THE  TIME  OF  THE  PREGNANCY.  In  some  cases  it 
is  of  importance  to  determine  how  far  the  pregnancy  has  advanced. 
Independently  of  an  estimate  made  of  this  time,  by  counting  from  the 
supposed  date  of  conception,  an  approximately  correct  conclusion  may 
be  obtained  by  an  objective  examination.  This  examination  gives  more 
satisfactory  results  in  primigravidse  than  in  multigravidae,  because  in  the 
former  the  changes  caused  by  pregnancy  are  more  characteristic  and 
typical.1  The  chief  means  in  making  this  diagnosis  are  the  changes  in 
the  neck  of  the  womb,  including,  in  multigravidse,  the  patency  of  the 
external  os,  and  the  progressive  permeability  of  the  cervical  canal ;  the 
size  of  the  uterus  as  learned  by  bimanual  examination,  and  the  distance 
of  the  fundus  above  the  pubes  as  measured  on  the  abdominal  wall ;  the 
changes  in  the  umbilicus,  and  the  formation  of  the  secondary  mammary 
areola ;  the  time  when  the  uterine  souffle  and  the  foetal  heart-sounds  be- 
come audible,  and  the  measurement  of  the  length  of  the  foetus.  With 
the  exception  of  the  last,  measuring  the  foetal  length,  all  these  have  been 
considered.  Ahlfeld's  method  of  ascertaining  the  length  of  the  foetus 
is  to  put  one  knob  of  the  calipers  in  the  vagina,  so  that  the  head  of  the 
foetus  is  touched  necessarily  through  the  thickness  of  the  uterine  wall, 
while  the  other  is  placed  at  the  fundus  of  the  uterus,  as  near  as  possible 
to  the  highest  part  of  the  breech,  the  abdominal  and  uterine  wall,  of 
course,  intervening.  The  length  of  the  child  is  about  twice  this  measure- 
ment. Knowing  what  its  length  usually  is  at  successive  months,  a  con- 
clusion may  be  drawn  from  the  length  of  the  foetus,  ascertained  by  this 
measurement,  as  to  the  time  of  the  pregnancy. 

.    *  Schroder. 


DATE  OF  LABOR.  209 

DURATION  OF  PREGNANCY/  Since  pregnancy  does  not  begin  imme- 
diately after  coition  or  insemination,  but  with  the  actual  union  of  the 
spermatozoid  and  ovule,  and  as  an  uncertain  time  intervenes  between 
insemination  and  conception,  it  is  impossible  for  us  to  know  its  actual 
duration.  We  know  in  all  cases  when  it  ends,  but  in  no  case  when  it 
begins.  In  those  rare  instances  in  which  pregnancy  was  known  to  have 
resulted  from  a  single  coition,  the  date  of  the  coition  does  not  corre- 
spond with  the  beginning  of  gestation.  It  is  probable  that  in  any  case 
some  hours,  and  in  many  several  days  intervened  before  the  combina- 
tion of  the  male  and  the  female  element  occurred  ;  Schroder  states  that 
the  interval  may  be  from  one  to  fifteen  days.  Further,  we  do  not  know 
whether  the  ovule  that  is  fecundated2  is  the  one  liberated  at  the  men- 
strual period  immediately  preceding  the  sexual  intercourse,  or  the  one 
corresponding  to  the  succeeding  menstrual  suppression,  or  one  escap- 
ing from  its  ovisac  in  the  menstrual  interval.  Hence  a  variation  of  a 
few  or  of  several  days  in  the  time  when  pregnancy  actually  begins. 

While  denied  this  certainty  of  knowledge,  general  observation  agrees 
in  making  the  period  of  gestation  nine  calendar  or  ten  lunar  months. 
Harvey  said  :  "  Unquestionably  the  ordinary  term  of  utero-gestation  is 
that  kept  in  the  womb  of  his  mother  by  our  Saviour  Christ,  of  men  the 
most  perfect ;  counting,  viz.,  from  the  festival  of  the  Annunciation  in 
the  month  of  March  to  the  day  of  the  blessed  Nativity,  which  we  cele- 
brate in  December.  Prudent  matrons,  calculating  after  this  rule,  as 
long  as  they  note  the  day  of  the  month  in  which  the  catamenia  usually 
appears,  are  rarely  out  of  their  reckoning,  but  after  ten  lunar  months 
have  elapsed  fall  in  labor  and  reap  the  fruit  of  their  womb  the  very 
day  on  which  the  catamenia  would  have  appeared  had  not  impregnation 
taken  place."3  Dr.  Matthews  Duncan  speaks  of  Harvey's  opinion  here 
quoted,  as  "  very  correct,"  and  also  states  that  his  remarks  tally  with 
the  late  Dr.  Tyler  Smith's  ingenious  views  upon  the  question. 

When  pregnancy  resulted  from  a  single  coition  the  average  interval 
between  it  and  labor  was  two  hundred  and  seventy-five  days.  The 
average  interval  between  the  end  of  menstruation  and  labor  is  two 
hundred  and  seventy-eight  days.  Variations  from  these  averages  will 
be  considered  subsequently. 

PREDICTING  THE  DATE  OF  CONFINEMENT.  Tables  for  readily  cal- 
culating the  time  of  labor  are  usually  found  in  "  Physicians'  Visiting 

1  Montaigne  has  the  following  remarks  upon  the  duration  of  pregnancy :  "  Here,  again,  are  the 
physicians,  the  philosophers,  the  lawyers,  and  the  divines,  by  the  ears  with  our  wives,  about  the 
dispute,  '  for  what  time  women  carry  their  fruit.'  and  I  for  my  part,  by  the  example  of  myself,  side 
with  those  who  maintain  that  a  woman  goes  eleven  months  with  child.  The  world  is  built  upon 
this  experience ;  there  is  not  so  simple  a  little  woman  that  cannot  give  her  judgment  in  all  these 
controversies,  and  yet  we  cannot  agree."  .But  Montaigne  wrote  in  the  sixteenth  century. 

Referring  to  the  opinions  as  to  the  duration  of  pregnancy,  there  is  found  in  Herodotus  the  story 
of  a  Spartan  king.  Demaratus,  born  seven  months  after  his  mother's  marriage,  and  in  answer  to  the 
charge  of  his  illegitimacy  she  made  this  statement:  "Women  bring  forth  at  nine  months  and 
seven,  and  all  do  not  complete  ten  months." 

"His  found  by  careful  examination  of  16  embryos  that  in  12  the  stage  of  their  development 
showed  them  to  be  the  result  of  impregnation  at  the  time  of  the  first  missing  menstrual  period, 
while  the  4  others  corresponded  to  the  last  preceding  menses,  and  it  only  remains  to  prove  by  a 
more  extended  series  of  observations  which  is  of  more  frequent  occurrence." — Winckel. 

3  Professor  A.  R.  Simpson,  referring  to  Harvey's  statement  fixing  the  duration  of  pregnancy  as  275 
days,  remarks :  "The  dates  are  derived  only  from  the  teachers  of  the  Roman  Catholic  Church,  and 
when  their  true  meaning  is  investigated  it  is  found  that  the  25th  of  March  was  held  as  Lady-day 
in  Pagan  Rome,  in  honor  of  Cybele,  the  mother  of  the  Babylonian  Messiah,  long  before  the  era  of 
our  Lord ;  while  the  25th  of  December  was  kept  among  many  Gentile  people  as  the  birthday  of  the 
Son  of  that  "  Queen  of  Heaven.'  " 

14 


210  PHYSIOLOGY  OF  PREGNANCY. 

Lists,"  and  therefore  it  is  unnecessary  to  insert  any  here.  But,  more- 
over, there  are  simple  rules  by  which  the  calculation  can  be  made, 
and  therefore  such  tables  and  "periodoscopes"  may  well  be  omitted. 
One  plan  is  to  count  the  number  of  days  between  the  beginning  of  the 
last  menstruation  and  that  of  the  one  immediately  preceding  it,  and 
multiply  the  number  by  ten;  labor  comes  on  at  what  would  have  been 
the  tenth  menstrual  period  had  not  pregnancy  occurred.  A  much  sim- 
pler rule,  given  by  Tarnier,  is  this:  Count  nine  calendar  months  from 
the  cessation  of  the  flow,  and  add  five  days.  Or  we  may  add  five  days 
to  the  date  when  the  flow  stopped  and  count  back  three  months.  Thus, 
a  woman  ceased  to  menstruate  on  the  fifteenth  of  February,  now  adding 
five  to  fifteen  we  have  the  twentieth  of  the  month,  and  then  counting 
back  from  the  twentieth  of  February  three  months,  we  find  that  the 
twentieth  of  November  is  the  probable  day  of  labor. 

An  objection  to  the  plan  of  counting  the  duration  of  the  pregnancy 
from  the  duration  of  the  menstrual  cycle  arises  from  the  fact  that  in 
many  women  this  is  not  a  uniform  period,  often  varying  from  one 
month  to  another,  and  it  certainly  is  very  different  in  different  individ- 
uals. According  to  such  plan,  the  woman  who  njenstruates  every  three 
weeks  ought  to  have  her  pregnancy  end  in  two  hundred  and  ten  days, 
while  another  whose  period  may  happen  to  be  thirty-one  days  would 
have  her  pregnancy  protracted  to  three  hundred  and  ten  days. 

"Quickening"  has  been  by  some  regarded  as  so  uniformly  occurring 
at  four  months  and  a  half  that  the  time  of  the  ending  of  pregnancy 
might  be  determined  from  the  date  when  this  was  observed.  But,  as 
previously  stated,  this  phenomenon  is  not  so  regular  in  its  time  of  mani- 
festation as  to  give  accurate  guidance.  In  some  cases  it  may  serve  to 
correct  an  error  that  has  been  made  in  regard  to  the  date  of  the  last 
menstruation,  and  may  assist  in  forming  a  probable  conclusion  as  to  the 
time  when  labor  will  occur. 

While  it  is  usual  to  speak  of  predicting  the  day  of  confinement,  it 
should  be  remembered  that  the  prediction  is  only  a  probable  one,  and 
indeed  that  the  day  when  labor  occurs  is  most  frequently  either  just 
before  or  just  after  this. 

PRECOCIOUS  BIRTHS.  La  Motte  has  given  the  history  of  a  woman 
who  was  delivered  of  a  child  seven  months  after  marriage ;  her  husband 
suspected  her  chastity,  but  seven  months  after  her  convalescence  she  was 
delivered  again,  greatly  to  the  relief  of  the  husband's  mind  ;  her  daugh- 
ters married,  and  each  of  them  was  delivered  at  seven  months.  He 
also  mentions  another  case  in  which  marriage  took  place  the  day  that 
the  bride  left  the  convent,  and  just  seven  months  subsequently  labor 
occurred ;  after  recovery  she  again  became  pregnant,  and  this  pregnancy 
also  lasted  only  seven  months.  Both  children  lived. 

One  of  these  cases  was  quoted  by  Depaul,  and  he  observed  that  while 
precocious  births  are  generally  admitted,  the  unanswerable  facts  proving 
them  are  very  rare.  The  late  Dr.  Hodge  taught  that  in  many  instances 
strong  and  healthy  children  are  delivered  before  the  usual  time.  The 
same  belief  was  expressed  by  Spiegelberg.  Yet  it  seems  improbable 
that  a  child  born,  for  example,  at  seven  months  will  present  the  devel- 


PROLONGED  PREGNANCY.  211 

opment  of  one  born  at  nine  months.1  Ronaldson2  has  reported  a  case 
of  "early  viability/7  the  child  being  born  six  calendar  mouths  and  nine 
days  after  coition. 

The  French  law  recognizes  as  legitimate  a  child  born  six  months  (180 
days)  after  marriage ;  but  while  this  is  a  legal  viability,  yet  it  is  quite 
exceptional  for  a  child  born  before  the  completion  of  seven  months  to 
live,  and  even  if  born  then,  very  great  care  is  generally  necessary  to 
preserve  its  life.  The  nearer  the  time  of  birth  approaches  the  normal 
the  greater  the  probability  of  the  child  living.  While  not  claiming 
that  a  child  born  at  eight  months  will  be  as  vigorous  and  as  well  devel- 
oped as  one  born  at  full  term,  it  is  not  unreasonable  to  believe  that  in 
some  cases  the  foetus  may  develop  somewhat  more  rapidly,  its  growth 
favored  especially  by  abundant  supply  of  nutriment,  than  in  other 
cases,  just  as  seeds  may  germinate  more  rapidly,  or  plants  have  their 
fruits  and  flowers  earlier  in  one  soil  than  in  another ;  in  other  words, 
there  may  be  precocious  births,  but  the  boundary  within  which  this  may 
occur,  though  incapable  of  being  defined,  is  probably  a  very  narrow  one. 

A  case  recently  under  my  care  has  convinced  me  that  occasionally  precocious 

births  do   occur :    Mrs.  ,  six    years    married,  pregnant   three    times,  each 

pregnancy  ending  in  miscarriage,  one  in  the  fifth  month,  the  others  at  earlier 
dates.  The  patient  first  came  under  my  care  three  years  ago,  on  account  of 
retroversion  of  the  uterus.  In  October,  1893,  I  attended  her  in  a  miscarriage. 
In  the  spring  of  1894  menstruation  became  somewhat  irregular,  and  there  were 
occasional  discharges  of  blood  in  the  intervals.  I  thought  these  probably  re- 
sulted from  an  early  and  incomplete  abortion,  not  included  in  the  list  of  three, 
and  determined  to  curette  the  uterus.  This  curetting  was  done  on  the  18th  of 
June,  and  followed  by  an  injection  of  Churchill's  tincture.  She  left  the  hospital 
the  last  day  of  the  month,  and  menstruation  did  not  reappear.  Pregnancy  was 
soon  believed  to  exist,  the  belief  becoming  a  certainty  in  October.  In  consequence 
of  a  severe  fright,  fire  breaking  out  in  her  house,  premature  labor,  no  premoni- 
tory symptoms  whatever,  especially  no  change  in  form,  occurred  on  the  7th  of 
February,  and  after  twenty-four  hours  she  was  spontaneously  delivered  of  a 
living  female  child,  which  weighed  nearly  seven  pounds.  The  child,  though  not 
so  strong  nor  so  active  as  one  born  at  term,  certainly  greatly  exceeded  in  vigor 
that  usually  observed  in  a  seven  months'  child :  the  fontanelles  were  much  larger 
than  in  a  child  born  at  term,  and  the  cranial  bones  less  firm.  The  infant  was 
kept  in  Auvard's  incubator  for  three  weeks.  The  pregnancy  could  not  have 
exceeded  226  days,  or  eight  lunar  months  and  two  days,  and  the  assurance  was 
given  me  that  it  was  even  less  than  this  period.  It  is  impossible  to  admit 
that  even  if  pregnancy  was  presenfat  the  time  of  the  curetting  it  could  continue 
after  it.  I  am,  therefore,  led  to  believe  with  La  Motte,  and  some  other  of  the 
older  obstetricians,  in  a  more  rapid  development  of  the  foatus  in  exceptional  cases 
than  that  usually  observed. 

PROLONGED  PREGNANCY.  Few  questions  in  obstetrics  have  caused 
more  controversy  than  as  to  whether  the  period  of  utero-gestation  can 
be  materially  prolonged  beyond  280  days.  It  is  still  unsettled.  As 
late  as  1870,  in  a  trial  before  the  Court  of  Queen's  Bench,  upon  the 
charge  of  seduction,  very  contradictory  evidence  as  to  the  prolongation 
of  the  ordinary  period  of  pregnancy  was  given  by  distinguished  obstet- 
ricians. In  the  United  States  obstetric  authorities  have  generally  up- 

1  It  is  somewhat  remarkable  that  we  have  comprised  within  a  few  lines  in  the  nineteenth  book  01 
the  Iliad,  115-119,  not  only  a  statement  of  the  normal  period  of  human  pregnancy,  nine  months, 
but  also  an  example  of  the  successful  induction  of  labor  at  less  than  seven  calendar  months,  and 
of  the  prolongation  of  pregnancy  beyond  nine  months  in  another  subject. 

2  Edinburgh  Obstetrical  Society's  Transactions,  vol.  vi. 


212  PHYSIOLOGY  OF  PREGNANCY. 

held  the  view  that  gestation  may  be  prolonged.  Dewees  asserted 
that  in  each  of  four  women  under  his  observation  pregnancy  lasted  ten 
calendar  mouths.  Bedford  stated  that  there  is  undoubted  evidence  that 
pregnancy  occasionally  extends  beyond  300  days.  Dr.  Hodge  gave 
from  his  own  practice  a  case  in  which  he  regarded  it  as  certain  that 
pregnancy  continued  302  days.  Warrington,  apparently  founding  his 
opinion  upon  the  evidence  in  the  Gardner  Peerage  case,  says  that  some 
women  have  been  pregnant  ten  calendar  months  (311  days).  Meigs, 
after  detailing  Asdrubali's  case,  in  which  pregnancy  was  alleged  to  have 
continued  thirteen  months  and  twenty-two  days,  and  expressing  his 
belief  in  its  truth,  narrated  the  history  of  a  pregnant  woman  under  his 
own  care,  whose  pregnancy  lasted  420  days.  American  physicians  have 
reported  in  medical  journals  a  few  instances  of  protracted  gestation. 
Among  these  is  that  of  a  case  in  which  pregnancy  was  believed  to  have 
continued  330  days.1  Dr.  L.  A.  Rodenstein  has  given  four  cases  of  pro- 
longed pregnancy;2  he  suggests  as  the  probable  limit  to  this  increased 
duration,  two  mouths. 

Rossie  has  published3  a  case  in  which  pregnancy  did  not  end  until 
317  days  after  coition.  McTavish4  gives  a  case  in  which  he  believes 
pregnancy  lasted  318  days,  and  Maur,5  one  of  334  days. 

It  has  been  in  this  country  judicially  decided  that  pregnancy  may  last 
317  days. 

Thomson  has  recently  reported  a  case  in  which  pregnancy  lasted 
317  days  from  the  last  menstruation,  or  301  from  the  last  coition.6 

Some  of  the  most  eminent  of  foreign  physicians  have  held  that  pro- 
longed gestation  may  occur.  Naegele,  in  his  well-known  work,  asserts 
that  there  are  undoubtedly  cases  in  which  the  pregnancy  has  lasted  300 
days  and  even  longer.  The  late  Dr.  Churchill7  said:  "Dr.  Mont- 
gomery relates  two  cases  in  his  work,  one  of  which  came  under  my 
observation  ;  in  the  first,  the  gestation  continued  291  days,  and  in  the 
second,  forty-one  weeks  and  two  or  three  days  at  least."  He  adds  to 
this  statement,  that  the  question  being  one  chiefly  of  authority,  positive 
evidence  must  infinitely  outweigh  mere  negation.  Spiegelberg8  has 
remarked  that  the  variations  in  pregnancy  lie  chiefly  between  the  265th 
and  the  280th  days ;  cases  in  which  a  foetus  has  matured  in  a  shorter 
time  are  rare,  somewhat  more  frequent  are  those  in  which  birth  took 
place  after  280  days.  Individual  conditions  certainly  have  an  influence 
upon  the  pregnancy,  thus  primiparous  and  legitimate  pregnancies  end 
earlier  than  their  opposites.  He  also  refers  to  the  dependence  of  the 
duration  of  the  pregnancy  upon  the  menstrual  cycle,  as  pointed  out  by 
Cederschojold  and  Berthold,  and  hence  variations  in  individuals  accord- 
ing to  their  menstrual  periods ;  there  may  be  also  variations  in  the  same 
person  in  different  pregnancies.  Wiuckel,  from  his  own  study  of  cases 
in  which  pregnancy  followed  a  single  cohabitation,  and  from  the  obser- 
vations of  others,  reaches  the  following  conclusion  :  The  average  dura- 
tion of  pregnancy  is  about  280  days ;  it  may  vary,  however,  from  240 

1  Boston  Medical  and  Surgical  Journal,  May,  1859. 

2  American  Journal  of  Obstetrics,  June,  1882.  3  Ibid.,  January,  1886. 

*  New  York  Medical  Journal,  April,  1889.  *  Ibid.;  May,  1889. 
6  London  Obstetrical  Society's  Transactions,  vol.  xxvii. 

*  Theory  and  Practice  of  Midwifery.^  8  Op.  cit. 


PROLONGED  PREGNANCY.  213 

to  320  days,  and  perhaps  even  exceed  this  latter  limit,  and  such  excess 
is  by  no  means  so  rare  as  was  formerly  supposed,  for  in  6.8  per  cent, 
the  duration  is  over  300  days.  Ahlfeld  states  that  pregnancy  in  women 
varies  from  220  to  330  days,  counting  from  coition.  He  also  quotes 
the  case  reported  by  Sarwey  in,  which  labor  occurred  341  days  after 
the  last  menstruation,  as  doubtful  because  the  date  of  impregnation  was 
not  known.  So,  too,  Olshausen1  has  said  that  the  duration  should  not 
be  restricted  to  300  days,  but  the  limit  ought  to  be  advanced  to  320  or 
325  days.  Hohl  is  quoted  by  Olshauseu,  op.  cit.,  to  the  eifect  that  pro- 
longation to  308  days  is  not  rare,  and  that  even  321  and  336  (case  of 
von  Rieche)  may  occur. 

On  the  other  hand,  Stoltz  takes  the  position  that  pregnancy  cannot 
be  prolonged  more  than  fifteen  days ;  Depaul,  referring  to  the  French 
law  making  a  child  legitimate  born  300  days  after  the  departure  or 
death  of  the  husband,  considered  the  limit  very  large ;  Kleinwachter 
denies  prolonged  pregnancy ;  Dr.  Robert  Barnes  holds  that  a  pregnancy 
lasting  300  days  is  highly  improbable ;  and  Tarnier  states  that  it  is 
impossible  to  admit  an  iutra-uterine  pregnancy  passing  the  highest 
limit  of  normal  pregnancy  unless  some  obstruction  at  the  cervix  prevents 
delivery. 

That  labor  may  be  delayed  for  a  few  weeks  is  the  belief  of  many 
obstetricians  from  their  personal  observations.  Thus,  in  illustration, 
it  is  not  uncommon  for  a  woman,  in  most  cases  a  primigravida,  who 
passes  the  time  at  which  her  delivery,  counting  from  her  last  menstrua- 
tion, was  expected,  and  then  after  a  delay  of  two,  three,  or  even  four 
weeks,  falls  in  labor ;  the  labor  is  tedious,  a  large  head,  its  ossification 
further  advanced  than  is  usually  found  at  birth,  is  to  be  moulded ;  in 
some  cases  the  forceps  must  be  used,  but  whether  the  child  be  delivered 
spontaneously  or  artificially,  it  weighs  considerably  more  than  the 
average,  and  not  unseldom  is  stillborn.  Delore  mentions  an  instance 
of  a  primigravida  whose  gestation  lasted  a  month  beyond  the  usual 
period  ;  Duncan,  one  of  a  multigravida  in  whom  the  pregnancy  also 
lasted  a  month  over  time,  the  child  weighed  ten  pounds  and  four  ounces, 
and  the  placenta  two  pounds.  Schroder  quotes  the  case  reported  by 
Rigler,  as  "  a  very  conclusive  one  "  in  proof  of  prolonged  pregnancy. 
A  woman  four  weeks  after  the'expected  term,  give  birth  to  a  dead  male 
infant,  weighing  ten  pounds  and  a  quarter,  the  hair  and  the  nails  were 
well  developed,  and  the  placenta  weighed  more  than  three  pounds. 

Cases  of  this  kind  will  be  admitted  by  most  as  proving  the  prolonga- 
tion of  pregnancy.  Such  facts,  belonging  so  generally  to  personal  ex- 
perience, have  more  weight  than  an  appeal  to  the  uniformity  of  Nature's 
laws.  The  argument  drawn  from  occasional  instances  of  prolonged 
pregnancy  in  some  of  the  inferior  animals,  also  has  weight  in  sustaining 
the  view  that  this  is  not  impossible  in  the  human  female.  For  example, 
the  average  duration  of  pregnancy  in  the  cow  is  282  days,  but  the  time 
may  be  prolonged  to  321  days. 

Reese,2  in  his  excellent  manual,  takes  the  ground  that  it  is  possible 
for  human  pregnancy  to  be  prolonged  beyond  the  usually  admitted  nor- 

1  Centralblatt  f.  Gynakol.,  1889. 

2  Text-book  of  Medical  Jurisprudeuce  and  Toxicology. 


214  PHYSIOLOGY  OF  PREGNANCY. 

mal  period,  but  that  the  question  how  far  beyond  is  more  difficult  to 
answer,  though  the  greater  the  amount  of  the  deviation,  the  stronger 
and  more  convincing  should  be  the  proofs.  He  further  indorses  the 
statement  of  Taylor  to  the  effect  that  we  must  "  be  prepared  to  admit 
either  that  conception  may  in  some  cases  be  delayed  for  so  long  a  period 
as  five  to  seven  weeks  after  intercourse,  or  that  there  may  be  a  differ- 
ence of  from  five  to  seven  weeks  in  the  duration  of  pregnancy." 

In  regard  to  the  question  of  a  perfectly  matured  child  being  born 
prior  to  the  normal  period  of  pregnancy,  he  criticises  the  evidence 
given  by  the  late  Sir  James  Simpson  in  an  English  case,  in  which  the 
legitimacy  of  a  child  was  made  to  depend  upon  the  period  of  the 
mother's  gestation,  259  days,  Sir  James  testifying  that  it  was  impossi- 
ble for  a  child  perfectly  matured  to  be  born  three  weeks  before  the 
usual  term. 

I  am  indebted  to  James  P.  Baker,  Esq.,  of  Indianapolis,  for  the 
following  presentation  from  a  legal  standpoint  of  the  duration  of 
pregnancy : 

The  period  of  gestation  is  frequently  a  matter  of  judicial  inquiry,  particularly 
in  bastardy  proceedings  and  in  controversies  among  heirs  affecting  legitimacy. 
Lord  Coke,  who  was  one  of  the  great  masters  of  the  common  law,  in  his  work 
upon  Littleton,  written  nearly  three  hundred  years  ago,  held  that  nine  months, 
or  forty  weeks,  is  the  longest  time  allowed.  Mr.  Hargrave,  in  his  edition  of 
Coke  upon  Littleton,  at  page  123  b,  carefully  reviewed  the  law,  and  came  to  a 
different  conclusion.  In  summing  up,  he  said : 

"  The  precedents,  therefore,  so  far  from  corroborating  Lord  Coke's  limitation 
of  the  ultimum  tempus  pariendi,  do,  upon  the  whole,  rather  tend  to  show  that  it 
hath  been  the  practice  in  our  courts  to  consider  forty  weeks  merely  as  the  more 
usual  time,  and  consequently  not  to  decline  exercising  a  discretion  of  allowing 
a  longer  space  where  the  opinion  of  physicians  or  the  circumstances  of  the  case 
have  so  required.  In  the  course  of  our  inquiries  into  the  subject  of  this  note 
we  were  curious  to  know  the  general  sentiment  of  that  eminent  anatomist,  Dr. 
Hunter,  on  three  interesting  questions.  These  were,  What  is  the  usual  period 
of  a  woman's  going  with  child?  What  is  the  earliest  time  for  a  child's  being 
born  alive  ?  and  What  is  the  latest  f  " 

Dr.  Hunter's  answer  was  as  follows  : 

"  1.  The  usual  period  is  nine  calendar  months ;  but  there  is  very  commonly  a 
difference  of  one,  two,  or  three  weeks.  2.  A  child  may  be  born  alive  at  any 
time  from  three  months ;  but  we  see  none  born  with  powers  of  coming  to  man- 
hood, or  of  being  reared,  before  seven  calendar  months,  or  near  that  time.  At 
six  months  it  cannot  be.  I  have  known  a  woman  bear  a  living  child,  in  a  per- 
fectly natural  way,  fourteen  days  later  than  nine  calendar  months,  and  I  believe 
two  women  to  have  borne  children  alive  in  a  natural  way,  above  ten  calendar 
months  from  the  hour  of  conception." 

Mr.  Hargrave's  note  has  been  frequently  quoted  by  the  courts  up  to  the  present 
time,  and  is  still  regarded  as  a  sound  exposition  of  the  law.  The  question  may 
arise,  Which  Dr.  Hunter  gave  the  above  reply  ?  Hargrave  lived  in  London,  and 
wrote  the  preface  to  his  edition  of  Coke  in  January,  1785.  Dr.  William  Hunter 
died  in  1783.  Dr.  John  Hunter,  his  brother,  died  In  1793.  The  note  was  prob- 
able written  near  the  time  of  the  completion  of  Mr.  Hargrave's  work.  It  is 
probable,  therefore,  from  these  facts,  though  not  certain,  that  John  Hunter  was 
the  author  of  the  reply.  But  a  certainty  seems  to  be  established  by  Mr.  Har- 
grave referring  to  Dr.  Hunter  as  "  that  eminent  anatomist,"  a  designation  which 
applied  more  especially  to  John  than  to  William  Hunter,  for  the  latter  was 
more  celebrated  as  an  obstetrician. 

Judges,  like  doctors,  are  liable  to  differ,  and  the  decisions  of  courts  have  not 
been  entirely  harmonious  as  to  the  period  of  gestation.  In  the  case  of  O'Brian 
v.  The  State  ex  rel.  Swift,  14th  Ind.  469,  the  Supreme  Court  of  Indiana  say : 


PROLONGED  PREGNANCY.  215 

"Those  who  have  investigated  the  subject  know  that  in  the  course  of  nature 
a  child  living  and  capable  of  surviving  to  the  ordinary  age  of  man  may  be  born 
in  seven,  and  may  not  be  born  until  the  expiration  of  ten  months  from  the  ces- 
sation of  the  catamenia  indicating  the  time  of  its  conception." 

The  case  of  Duck  v.  The  State  ex  rel.  Dill,  17th  Ind.  210,  was  a  prosecution 
for  bastardy.  In  such  a  case  the  question  always  is,  "  Is  the  defendant  the  father 
of  the  child?"  Any  evidence  tending  to  show  that  any  other  man  is  the  father 
is  admissible.  The  child  was  born  on  September  18,  1858.  On  the  trial  the 
defendant  offered  to  prove  that  the  relatrix  had  had  sexual  intercourse  with 
another  person  in  the  first  week  of  November,  1857.  The  evidence  was  rejected. 
The  Supreme  Court  held  that  this  evidence  was  rightly  rejected,  and  said  : 

'*  It  is  true,  experience  proves  that  the  period  of  gestation  is  almost  as  variable 
in  individual  cases,  though  within  narrow  limits,  as  that  of  the  length  of  human 
life,  but  the  longest  period  we  have  ever  known  to  be  judicially  allowed  was  313 
days.  See  the  case  of  Commonwealth  v.  Hoover,  3d  Clark,  Pa.  514.  In  the 
case  at  bar  the  evidence  might  have  covered  a  period  of  322  days." 

A  still  longer  time  was  judicially  allowed,  however,  in  the  case  of  the  United 
States  v.  Collins,  tried  in  the  U.  S.  District  Court  for  the  District  of  Columbia  in 
1809,  and  reported  inCranch's  Circuit  Court  Reports,  vol.  1,  page  592.  The  case 
was  an  indictment  for  not  supporting  a  bastard  child.  The  mother  was  received 
as  a  witness.  The  attorney  for  the  government  objected  to  the  cross-examina- 
tion as  to  her  connection  with  other  men  than  the  defendant.  The  Court  over- 
ruled the  objection,  but  limited  the  time  of  inquiry  to  a  period  of  not  more  than 
twelve  months  nor  less  than  six  months  before  the  birth  of  the  child.  This  is 
an  extreme  case.  In  Paul  v.  Padleford,  16  Gray  (Mass.),  263,  a  bastardy  prose- 
cution, the  Court  refused  to  allow  proof  of  acts  of  intercourse  of  the  plaintiff 
with  other  persons  than  the  defendant,  at  a  time  more  than  ten  months  and 
twelve  days  before  the  birth  of  the  child.  In  Phillips  v.  Allen,  2d  Allen  (Mass.), 
453,  the  Court  said  : 

"  The  child  was  born  in  eight  months  after  the  marriage,  and  the  fact  that  a 
child  is  born  thus  soon  after  the  husband  had  first  access  to  the  wife  does  not 
prove  beyond  all  reasonable  doubt  that  the  child  is  not  his.  There  are  ancient 
decisions  that  gestation  somewhat  more  than  nine  months  after  the  husband 
could  have  had  access  to  the  wife,  does  not  disprove  the  legitimacy  of  the  child. 
See  Hargrave's  note  to  Coke's  Lift.  123  b,  where  these  decisions  are  cited,  and 
where  in  support  of  them  the  testimony  of  Dr.  Hunter  is  introduced,  expressing 
his  opinion  that  gestation  often  varies  from  one  to  three  weeks  from  nine  cal- 
endar months,  and  that  children  are  sometimes  born  in  seven  months  from  con- 
ception, and  live  and  grow  to  manhood." 

In  Eddy  v.  Gray,  4  Allen  (Mass.),  435,  which  was  a  bastardy  prosecution,  the 
Court  below  had  admitted  testimony  tending  to  show  illicit  intercourse  by  the 
complainant  with  other  men  than  the  defendant  at  a  period  of  time  more  than 
ten  months  before  the  birth  of  the  child.  The  Court  said  : 

"  Such  testimony,  in  the  absence  of  proof  that  the  period  of  gestation  extended 
beyond  the  usual  duration  according  to  the  common  and  natural  course  of  life, 
which  is  recognized  as  well  by  legal  as  medical  authorities,  is  inadmissible,  and 
should  have  been  excluded.  See  Coke's  Litt.  123  b,  and  note  by  Hargrave." 

In  the  recent  case  of  Ronan  v.  Dugan,  126  Mass.  p.  176,  a  prosecution  in  bas- 
tardy, the  Supreme  Court  of  Massachusetts  say  : 

"  In  cases  of  this  kind,  the  admissibility  of  evidence  of  illicit  intercourse  of 
the  complainant  with  any  other  man  than  the  defendant  depends  upon  the 
relation  to  the  time  when  the  child  was  born.  In  Eddy  v.  Gray,  4  Allen,  p.  435, 
where  the  intercourse  offered  to  be  proved  occurred  more  than  ten  months  before 
the  birth,  the  evidence  was  held  to  be  inadmissible  without  proof  that  the  period 
of  gestation  was  prolonged  beyond  the  usual  duration.  We  see  no  reason  why 
the  same  rule  should  not  be  followed  where  the  intercourse  offered  to  be  proved 
took  place  less  than  seven  and  a  half  months  before  the  birth,  in  the  absence  of 
the  proof  that  the  birth  was  premature." 

In  such  a  case  the  Tennessee  Code  limits  the  inquiry  between  the  first  of  the 
tenth  and  the  first  of  the  sixth  month  next  before  the  birth  of  the  child.  See 
Crawford  v.  The  State,  7,  Baxter,  41. 

Wharton,  in  his  work  on  Evidence,  at  section  344,  says : 


216  PHYSIOLOGY  OF  PREGNANCY. 

"  The  court  will  take  judicial  notice  of  the  ordinary  periods  of  gestation,  so 
as  to  assume  the  non-legitimacy  of  children  born  ten  months  after  intercourse, 
or  when  prior  non-intercourse  is  proved  five  months  after  the  act  of  intercourse." 

At  section  1300  he  says : 

"  The  time  of  conception  is  determined  by  the  Roman  practice  by  reckoning 
backward  from  the  time  of  birth ;  and  the  rule  is  that  there  must  be  not  less 
than  one  hundred  and  eighty-two  days  and  not  more  than  ten  months  to  estab- 
lish legitimacy.  German  jurists  have  continued  to  maintain  the  minimum  of 
one  hundred  and  eighty-two  days.  In  our  own  practice  the  question  of  legiti- 
macy, when  a  child  is  born  on  either  side  of  the  usual  limits  of  parturition,  is 
determined  on  the  testimony  of  experts  ;  though  in  cases  beyond  question,  the 
court  may  determine  what  is  notorious  as  a  part  of  the  ordinary  laws  of  nature." 

After  all,  the  light  of  the  courts  in  this  matter  is  reflected  light.  Physicians 
must  determine  the  matter ;  and  if  the  space  between  the  minimum  and  maxi- 
mum periods,  hitherto  allowed,  is  shown  to  be  too  long  or  too  short,  the  courts 
will  readily  follow  the  truth  as  it  is  made  manifest. 

MISSED  LABOR.  This  term,  introduced  by  Dr.  Oldham,  is  applied 
to  those  cases  in  which  a  foetus  dying  after  the  period  of  viability  has 
been  reached  is  retained  in  the  uterus  for  weeks,  or  even  months,  be- 
yond the  time  when  pregnancy  ordinarily  ends.  In  these  cases  nature 
makes  an  effort  at  the  normal  time  to  expel  the  contents  of  its  cavity, 
but  the  effort  fails,  and  the  pregnancy  continues  an  indefinite  period 
until  those  efforts  are  renewed  successfully,  or  the  contents  are  removed 
by  artificial  means. 

In  some  cases  the  failure  to  expel  the  contents  of  the  uterus  has  been 
from  resistance  of  the  os,  e.  g.,  the  obstacle  may  be  cancer  of  the  cer- 
vix. Other  explanations  given  by  Spiegelberg  are  an  abnormally  firm 
connection  of  the  ovum  with  the  uterus,  or  anomalous  degrees  of 
irritability. 

In  missed  labor  the  amnial  liquor  may  be  absorbed  and  the  foetus 
become  mummified  ;  in  other  instances  a  lithopaedion  results.  In  rarer 
cases  suppuration  of  the  foetus  may  occur,  the  purulent  discharge 
usually  finding  its  way  externally  through  the  vagina. 

It  has  been  shown  that  some  of  the  cases  of  supposed  missed  labor 
were  really  instances  of  ectopic  gestation,  or  of  gestation  in  a  rudi- 
mentary uterine  horn. 


CHAPTER   IX. 

THE    MANAGEMENT   OF    PREGNANCY. 

WOMAN  only  escapes  being  sick  twelve  times  a  year  by  having  an 
illness  which  lasts  nine  months,  was  the  assertion  of  a  once  famous 
French  litterateur.  Though,  of  course,  rejecting  this  statement  and 
denying  that  gestation  is  a  disease,  we  must  admit  that  it  has  many  dis- 
comforts, and  in  numerous  instances  causes  great  liability  to  pathological 
conditions,  and  in  some  these  conditions  are  manifested.  The  remark- 
able changes  that  occur  in  the  organism  or  in  the  organs  of  a  pregnant 
woman  may  open  the  way  for  maladies  which  are  manifested  during  or 
subsequent  to  the  pregnancy.  It  is  advisable,  therefore,  that  all  care, 
and  even  precautions,  be  taken  to  ward  off  threatened  dangers  and  to 
conduct  the  subject  safely  through  her  pregnancy,  both  in  her  own  in- 
terest and  in  that  of  her  offspring.1 

The  conduct  of  pregnancy  includes  hygienic  and  medical  care. 

HYGIENE  OF  PREGNANCY.  This  relates  to  food,  clothing,  air, 
exercise,  rest,  sleep,  bathing,  care  of  the  breasts,  and  to  the  mental  con- 
dition. 

FOOD.  In  many  cases  during  the  first  months  of  pregnancy  the 
disturbance  of  the  stomach,  and  the  less  active  life  often  consequent 
upon  this  disturbance,  and  in  some  the  associated  mental  anxiety,  lessen 
the  desire  for  food.  Nevertheless  it  is  better  that  an  effort  at  least  be 
made  to  have  regular  meals,  although  the  quantity  of  food  taken  may 
not  be  as  much  as  usual. 

In  some  cases  the  morning  sickness  may  be  lessened,  if  not  averted, 

1  That  special  care  of  the  pregnant  woman  was  in  early  times  regarded  as  important  is 
shown  by  the  practices  of  many  ancient  people,  and  by  the  injunctions  of  old  medical  writers. 
The  following,  for  example,  are  the  directions  given  by  Susru-fa,  the  earliest  known  medical 
writer  of  India,  who  lived  at  least  fourteen  hundred  years  before  the  Christian  era.  Many  of 
these  directions  are  wise,  while  the  reasorl  for  others  cannot  be  understood  : 

"  The  pregnant  woman  should  avoid  becoming  weary,  indulging  in  coition,  sleeping  in  the  day- 
time, watching  at  night,  sorrow,  climbing  into  a  wagon,  sitting  upright,  violent  movements, 
phlebotomy,  and  long-continued  exertion.  Her  longings  must  be  satisfied  in  order  that  she  may 
nave  a  strong  and  long-lived  child.  From  the  first  day  she  must  be  cheerful,  pious,  and  clean  in 
clothing  and  person.  She  should  not  touch  dirty  or  deformed  objects,  nor  eat  any  dry  or  spoiled, 
food.  She  must  not  go  out,  or  remain  in  an  empty  house,  or  go  to  the  holy  altar,  or  in  graveyards, 
or  near  trees ;  she  must  avoid  getting  angry,  carrying  loads,  or  talking  top  loud." 

Probably  the  first  recorded  example  of  the  hygiene  of  pregnancy  was  given  by  Samson's  mother 
when  pregnant  with  the  Jewish  Hercules ;  she  was  to  abstain  from  wine.  There  is  reason  for 
believing  that  drunkenness  among  the  Jewish  women  was  not  uncommon  at  that  time,  or  not 
long  subsequently,  as  the  interview  between  the  priest  Eli  and  Hannah,  recorded  in  the  first 
chapter  of  Samuel,  suggests.  Furthermore,  abstinence  from  intoxicating  beverages  in  pregnancy 
is  certainly  a  rule  of  prudence,  while  great  indulgence  in  them,  according  to  excellent  profes- 
sional authority,  is  very  mischievous.  For  example,  Dr.  Kirk,  Glasgow  Medical  Journal,  1885, 
remarks:  "For  my  part  I  am  convinced  that  indulgence  in  alcohol  beyond  the  most  moderate 
extent  is  frequently  in  the  last  degree  disastrous  to  a  pregnant  woman  and  her  progeny." 

Dr.  Norman  Kerr,  in  the  second  edition  of  his  work  upon  Inebriety,  London,  1889,  says  in  ref- 
erence to  the  influence  of  alcoholism  of  the  parents  upon  the  child  :  •'  The  mother  probably  is 
the  more  important  factor  of  transmission.  She  exerts  an  influence,  not  only  with  the  father  in. 
the  conception,  but,  in  addition,  during  the  whole  period,  of  utero-gestation  wields  a  special  in- 
fluence upon  the  unborn  child."  And  again  :  "  Considerable  numbers  of  the  children  of  female 
inebriates  succumb  to  intra-uterine  death.  Of  those  who  reach  the  period  of  birth,  a  goodly 
number  have  been  so  affected  in  the  womb  by  the  alcoholic  cerebral  and  meningeal  congestions, 
and  other  pathological  states  induced  by  alcohol,  that  they  die  from  hydrocephalus  or  convul- 
sions." 


218  PHYSIOLOGY  OF  PREGNANCY. 

by  the  patient  having  a  light  breakfast  an  hour  or  two  before  rising.1 
When  this  disorder  disappears  the  appetite  usually  returns,  and  in  some 
is  greater  than  it  was  before  pregnancy.  The  food  should  be  both 
animal  and  vegetable,  and  especially  include  digestible  fruits  in  their 
season  ;  for  the  latter  will  aid  in  preventing  the  constipation  which  so 
generally  attends  the  pregnant  condition. 

It  occasionally  happens  that  a  women  when  pregnant  desires  articles 
of  food  to  which  at  other  times  she  is  indifferent ;  and  these  desires 
ought  not  to  be  refused,  for  they  may  express  some  need  in  her  system 
for  certain  materials  which  are  thus  supplied  ;  they  are  very  different 
from  the  perversions  of  appetite  that  by  some  are  imagined  or  assumed. 

It  is  important  that  the  stomach  be  not  overloaded  at  any  time, 
and  especially  in  the  evening.  When  the  uterus  encroaches  most  upon 
the  stomach  in  the  latter  part  of  pregnancy  it  is  generally  the  case  that 
only  a  small  quantity  of  food  can  be  taken  at  a  time,  and  then  the 
meals  may  be  more  frequent  than  usual. 

Alcoholic  liquors  ought  not  to  be  used,  but  the  drink  should  be 
milk,  water,  or  chocolate  ;  those  who  are  accustomed  to  coffee  and  tea 
will  doubtless  continue  them,  but  these  beverages  should  not  be  strong, 
nor  taken  in  large  quantities. 

CLOTHING.  This  should  be  such  as  will  not  hinder  the  development 
of  the  abdomen  and  the  breasts,  and  at  the  same  time  will  protect  from 
cold.  The  word  enceinte,  meaning  in  Latin  ungirdled  or  without  girdle, 
commemorates  the  custom  of  Roman  women,  who,  when  they  became 
pregnant,  laid  aside  their  girdle,  the  fascia  mamittaris,  and  it  suggests 
avoiding  all  compression  of  the  body.  Baudelocque  mentions  the  case 
of  a  girl  who  sought  to  conceal  her  pregnancy  by  tight  lacing,  and  thus 
caused  a  dangerous  hemorrhage.  The  corsets  should  be  quite  loose ; 
the  garters,  if  tight,  may  cause  oedema  of  the  legs,  or  varicose  veins. 
Insufficient  or  unseasonable  clothing  may  lead  to  an  acute  affection  of 
the  respiratory  organs,  attended  with  violent  coughing,  and  the  latter 
cause  abortion ;  or  sudden  suppression  of  the  perspiration  occur  from 
exposure  to  cold  and  result  in  albuminous  nephritis.  The  high-heeled 
shoes  so  commonly  worn  by  ladies  tend  to  increase  the  forward  inclina- 
tion of  the  body,  and  thus  render  more  difficult  the  position  which  a 
pregnant  woman  must  take  to  preserve  the  centre  of  gravity  when 
standing  or  walking  ;  they  make  her  more  liable  to  missteps,  and  thus 
danger  of  falling,  thereby  injuring  herself  or  the  foetus,  and  of  jars  that 
may  case  partial  detachment  of  the  ovum.  If,  as  is  often  the  case  in 
the  multigravida3,  the  abdominal  wall  be  greatly  relaxed,  permitting 
decided  anteversion  of  the  uterus,  a  suitable  bandage  contributes  very 
much  to  the  patient's  comfort,  and  by  correcting  the  malposition  of  the 
womb  assists  in  preventing  an  unfavorable  presentation  of  the  foetus. 

AIR.     Pure  air  is  of  especial  importance  to  the  pregnant  woman,  for 

1  The  late  Professor  Meigs  stated :  "  Many  of  those  examples  that  consist  of  nausea  and 
vomiting  during  the  early  part  of  the  day,  but  which  cease  after  the  meridian  hour,  may  be  set 
aside  by  the  following  method  :  Let  a  cup  of  coffee,  with  a  toast,  be  brought  to  the  bedside  at  the 
earliest  morning  hour.  The  patient  should  be  called  from  her  sleep  to  take  this  preliminary 
breakfast  without  rising  from  bed.  As  soon  as  it  is  taken  let  her  lie  down  to  sleep  again,  if  pos- 
sible. It  appears  useless  to  offer  a  rationale  of  this  method.  I  am  very  confident,  however,  that, 
in  a  considerable  number  of  persons  it  will  be  found  to  put  a  sudden  stop  to  the  vomiting  as  well 
as  to  the  nausea.  Certainly  many  of  my  patients  have  been  speedily,  as  well  as  permanently, 
cured  by  it,  and  that  in  very  distressing  instances  of  the  nausea." 


THE  MANAGEMENT  OF  PREGNANCY.  219 

she  breathes  for  two,  and  is  eliminating  an  increased  quantity  of  toxic 
matter.  A  confined  atmosphere  has  an  injurious  influence  both  upon 
her  and  upon  the  foetus,  and  breathing  air  poisoned  by  carbonic  acid 
may  cause  abortion.  She  should  avoid  all  crowded  halls,  whether 
theatres,  concert  or  ball-rooms,  or  churches  ;  all  poisons  in  the  air,  such 
as  that  of  sewer  gas  or  of  infectious  diseases,  should  be  carefully  guarded 
against;  the  room  occupied  in  the  day  or  in  the  night  must  be  well 
ventilated  ;  if  possible,  a  part  of  each  day  ought  to  be  spent  in  the  open 
air. 

EXERCISE,  REST,  SLEEP.  If  a  woman  in  the  first  months  of  preg- 
nancy suifers  much  from  nausea  and  vomiting,  she  is  little  disposed  to 
exercise ;  she  is  weak  from  the  less  amount  of  food  taken  or  retained, 
and  any  movement  may  increase  the  gastric  irritability.  Again,  toward 
the  close  of  pregnancy  her  great  size  interferes  with  facility  of  move- 
ment; both  her  condition  and  instinct  ask  for  repose  more  than  for 
active  exertion  ;J  if  we  observe  the  conduct  of  pregnant  animals,  we 
find  that  as  parturition  draws  near  they  are  indisposed  to  exertion  and 
spend  much  of  their  time  lying  down.  But  in  woman  during  the 
intervening  time  daily  exercise  in  the  open  air,  carried  to  the  point  of 
slight  fatigue,  is  one  of  the  best  means  to  increase  her  vitality  and  that 
of  her  offspring ;  her  appetite  is  thus  improved,  her  digestion  better, 
and  refreshing  sleep  secured.  The  best  exercise  is  walking,  and  without 
some  special  reason  against  it,  that  should  be  chosen  rather  than  riding. 
All  violent  motions,  whether  active  or  passive,  such  as  riding  over 
rough  roads,  equitation,  dancing,  ascending  several  flights  of  stairs,  or 
lifting  heavy  weights  must  be  forbidden  ;  so,  too,  prolonged  exercise, 
causing  great  fatigue,  and  protracted  journeys  by  land  or  sea,  are  to  be 
avoided.  Regular  hours  of  rest  are  to  be  observed  ;  from  eight  to  ten 
of  the  twenty-four  may  be  given  to  sleep.  In  women  liable  to  abortion 
absolute  rest  is  often  necessary,  especially  at  the  time  corresponding 
with  a  monthly  period,  to  guard  them  against  the  danger ;  in  some  rare 
cases,  rest  in  bed  during  almost  the  entire  pregnancy  has  been  necessary 
in  order  to  avert  this  accident. 

CONJUGAL  RELATIONS.  Obstetric  writers  agree  in  forbidding  coition 
when  there  is  a  liability  to  miscarriage,  in  advising  it  to  be  less  fre- 
quent in  other  cases,  and  abstained  from  at  times  corresponding  with 
monthly  periods,  especially  the  third  and  seventh,  in  one  the  danger 
of  abortion,  in  the  other  that  of  premature  labor  being  greatest. 
Klein wiichter  remarks  that  coition  is  to  be  restricted  the  first  half  of 
pregnancy,  and  unconditionally  forbidden  the  second  half.  Dr.  Ben- 
jamin Ward  Richardson  directs  that  the  bed  of  the  pregnant  woman 
should  be  occupied  by  herself  exclusively.  Dr.  Richard2  says  that  if 
the  human  race  were  guided  by  the  example  of  animals,  and  if  it  per- 
fectly conformed  to  the  advice  of  nature,  which  most  frequently  inspires 
the  pregnant  woman  with  complete  indifference  and  even  some  aversion 
to  marital  caresses,  coition  during  gestation  would  be  entirely  abandoned. 

Other  writers  have  referred  to  the  aversion  which  Richard  mentions.  Thus 
Roederer3  enumerated  among  the  signs  of  pregnancy  viri  fastidium.  It  is  re- 

Stoltz.  2  Histoire  de  la  Generation.  8  Op.  cit. 


220  PHYSIOLOGY  OF  PREGNANCY. 

markable  that  among  the  signs  of  pregnancy  given  by  Susru-fa  the  dread  of 
coition  is  mentioned.  Stolz1  states  that  women  have  told  him  that  as  soon  as 
they  were  enceintes  they  had  horreur  du  mart,  some  of  them  by  this  sign  first 
knowing  that  they  were  pregnant. 

If  the  relation  between  husband  and  wife  had  no  higher  purpose  than  perpetu- 
ating the  race,  it  is  plain  that  sexual  intercourse  should  cease  when  the  vow  of 
nature  is  being  fulfilled ;  such  indulgence  may  cause  abortion,  and  has  been 
compared  to  ploughing  the  soil  when  the  seed  is  germinating  ;  in  many  cases  it 
is  painful,  excites  or  aggravates  leucorrhcea,  and  may  cause  more  or  less  reflex 
disorder.  There  is  a  moral  side  to  this  question.  Many  a  wife  must  have  less 
love  and  reverence  for  her  husband  when  she,  sick  and  suffering,  or  at  least  often 
wearied  by  the  growing  burden  she  bears,  her  mind  a  prey  to  anxious  fears  as  to 
the  issue  of  her  pregnancy,  is  the  victim  of  lust,2  a  lust  which  has  no  excuse  in 
her  desires,  no  demand  for  the  continuance  of  the  race.  Man  does  not  learn  that 
self-restraint  which  makes  him  purer  and  nobler,  but  nourishes  a  passion  that 
becomes  more  dangerous  by  such  exercise  than  it  could  by  any  voluntary  conti- 
nence during  his  wife's  pregnancy.  Admitting  that  the  state  of  society  changes 
the  instincts  of  nature,  and  that  the  indulgence  condemned,  in  many  cases,  brings 
no  immediate  and  obvious  injurious  physical  results,  it  may  well  be  questioned 
whether  most  obstetric  writers  have  not,  either  tacitly  or  explicitly,  granted  a 
license  which  leads  to  evil  rather  than  good. 

Both  Stoltz  and  Spiegelberg  disapprove  of  sexual  intercourse  in  pregnancy, 
but  the  former  states  that  such  disapproval  is  preaching  in  the  wilderness,  and 
the  latter  that  it  is  preaching  to  the  rocks.  Nevertheless  let  the  truth  be  spoken, 
whether  men  will  hear  or  not,  and  let  the  right  way  be  pointed  out,  though  a 
multitude  may  choose  to  go  in  the  wrong  path. 

Mantegazza,  L' Amour  dans  PHumanite,  says :  "The  origin  of  polygamy  may  be 
purely  hygienic.  In  many  countries  of  Africa  husbands  cannot  have  any  sexual 
relation  with  their  wives  during  the  period  of  pregnancy,  nor  sometimes  during 
the  period  of  lactation."  , 

BATHING.  The  frequency  and  temperature  of  baths  will  depend 
upon  a  patient's  previous  habits ;  but  usually  once  or  twice  a  week  is 
as  often  as  a  bath,  cold  or  warm,  is  advisable  :3  hot  baths,  whether  of 
the  feet  or  of  the  entire  person,  must  be  forbidden.  The  external 
genital  organs  should  be  bathed  daily  with  cool  water  as  a  protection 
from  erythema,  and  to  cleanse  from  increased  secretion  which  retained 
might  cause  irritation  ;  if  leucorrhoea  be  troublesome,  there  is  no  objec- 
tion to  tepid  vaginal  injections  of  water,  plain  or  medicated,  e.  g.,  with 
common  salt,  creolin,  chlorate  of  potassium,  or  borax ;  the  fluid  should 
be  injected  gently,  used  as  a  wash,  not  a  douche. 

The  late  Dr.  G.  W.  Lawrence,  for  many  years  a  distinguished  prac- 
titioner at  Hot  Springs,  Arkansas,  informed  me  that  abortions  have 
frequently  been  caused  by  the  use  of  hot  baths  at  this  famous  health 

1  Op.  clt. 

2  In  Swift's  terrible  satire  upon  human  beings,  given  in  Gulliver's  Voyage  to  the  Houyhnhnms, 
it  is  stated  that  "  the  she-yahoo  admits  the  male  while  she  is  pregnant,"  and  this  is  spoken  of  "  as 
such  a  degree  of  infamous  brutality  as  no  other  sensitive  creature  arrives  at." 

For  the  following  statements  I  am  indebted  to  Floss's  work,  Das  Weib : 

In  the  majority  of  heatht-n  nations  sexual  continence  is  observed  during  pregnancy.  Among 
many  the  abstinence  from  coition  has  arisen  from  the  belief  that  the  pregnant  woman  is  unclean. 
By  the  Medes  and  Persians  cohabitation  with  a  pregnant  woman  was  severely  punished.  Among 
some  people  polygamy  is  based  upon  abstinence  from  coition  in  pregnancy. 

The  old  Hebrews  and  the  Rabbis  in  the  Talmud  taught  that  coition  during  the  first  three  months 
of  pregnancy  was  very  injurious  to  both  the  mother  and  child.  Whoever  cohabited  on  the  ninetieth 
day  did  that  which  destroys  human  life,  but  the  prudent  Rabbi  Abaja  adds,  "  Since  we  cannot 
know  this  day  with  certainty,  God  preserves  the  simple  from  injury." 

The  ancient  Irans  very  severely  punished  cohabitation  with  the  pregnant  woman.  The  man  re- 
ceived 2000  lashes,  and  was  compelled  to  carry  1000  loads  of  heavy  and  1000  of  light  wood  to  the 
fire.  He  must  offer  in  sacrifice  1000  of  the  smaller  domestic  animals,  and  kill  1000  snakes,  1000  land 
lizards,  2000  water  lizards,  and  3000  ants,  and  lay  30  bridges  over  flowing  water. 

s  Warm  hip-baths  during  the  last  week  of  pregnancy  are  by  some  thought  useful  in  facilitating 
labor. 


THE  MANAGEMENT  OF  PREGNANCY.  221 

resort.  Tardieu,1  after  referring  to  the  universal  use  of  baths  under 
all  forms  by  those  practising  abortion,  observes  that  he  does  not  know 
a  single  instance  authorizing  him  to  believe  that  abortion  was  its  direct 
consequence. 

CARE  OF  THE  BREASTS.  It  has  been  previously  stated  that  the 
clothing  should  be  such  that  no  compression  of  these  organs,  especially 
of  the  nipples,  is  permitted.  If  the  nipple  be  small,  the  woman  should 
be  taught  to  use  her  thumb  and  finger  to  draw  it  out,  giving  it  suitable 
form  and  size ;  this  process  begun  some  months  before  labor,  and  ex- 
ercised for  a  few  minutes  each  day,  will  often  give  very  favorable  results. 
It  is  in  the  highest  degree  improbable  that  the  action  of  the  uterus  could 
be  thus  excited,  causing  abortion  or  premature  labor.  In  rare  cases  it 
may  be  advisable  to  use  at  first,  but  very  gently,  atmospheric  pressure 
by  means  of  a  breast-pump,  and  also  to  wear  a  firm  nipple-shield  which 
protects  the  organ  from  pressure,  and  gives  room  for  its  development. 
Keeping  the  nipple  too  constantly,  too  warmly  covered,  renders  the  skin 
more  delicate  and  sensitive,  and  therefore  is  to  be  avoided,  while  daily 
exposure  to  the  air  has,  according  to  Delore,  the  beneficial  effect  of  ren- 
dering the  epidermic  secretion  more  active.  Cleanliness  is  important, 
for  the  secretions  from  the  nipple  and  that  from  the  gland,  which  occur 
during  pregnancy  in  many  cases,  if  allowed  to  collect,  render  the  skin 
beneath  very  liable  to  become  excoriated  when  nursing  begins ;  the 
nipples,  therefore,  are  to  be  washed  each  day,  generally  with  simple 
water,  occasionally  soap  may  be  added.  Bathing  the  nipples  daily  with 
alcoholic  and  astringent  solutions  is  a  common  practice  in  pregnancy,  it 
being  believed  that  thereby  excoriations  and  fissures  are  prevented. 
But  it  is  doubtful  whether  the  theory  is  wise,  or  the  practice  justified 
by  results.  Such  applications  effectually  remove  the  secretion  and 
probably  lessen  the  activity  of  the  sebaceous  glands — thereby  in  some 
degree  doing  away  with  the  protection  nature  gives  to  surfaces  exposed 
to  contact  with  liquids — and  make  the  skin  hard  and  rigid,  which 
nature  meant  to  be  soft  and  pliable.  It  would  be  better  to  use  simply 
tincture  of  arnica,  bay  rum,  or  Cologne  water,  one  part  to  three  of  water, 
if  an  alcoholic  preparation  is  advisable;  but  in  any  case  there  should  be 
applied  to  the  nipple  at  night  a  small  quantity  of  cocoa  butter.  Cer- 
tainly the  prophylaxis  of  acute  disease  of  the  nipple  in  nursing  women, 
which  so  often  leads  to  mammary  inflammation,  is  better,  more  rationally 
sought  by  the  simple  means  just  mentioned,  than  by  those  in  common 
use. 

CONDITION  OF  THE  MIND.  Not  only  the  pregnant  woman's  own 
health,  but  that  of  her  child  is  in  some  degree  dependent  directly  or 
indirectly  upon  her  mental  state.  Her  sensibility  is  increased,  and 
therefore  she  should  be  carefully  guarded  against  injurious  impressions ; 
she  should  be  saved  all  needless  pain,  all  possible  petty  irritations,  all 
sudden  fright  or  shock.  The  exercise  of  a  cheerful  temper  should  be 
advised,  as  well  as  occupation  of  the  mind  in  some  useful  work,  in 
reading  or  study,  and  the  society  of  agreeable  friends,  with  occasional 
pleasant  recreation. 

1  Etude  MMico-legale  sur  PAvortement. 


222  PHYSIOLOGY  OF  PREGNANCY. 

MATERNAL  IMPRESSIONS.  The  question1  as  to  the  foetus  being  in- 
juriously affected,  whether  by  arrest  of  development,  malformation,  or 
"marks,"  in  consequence  of  impressions  made  upon  the  mother's  mind, 
is  one  of  great  interest,  and  probably  of  no  mean  importance.  These 
psychical  conditions  may  be  subjective  or  objective;  that  is,  may  origin- 
ate in  the  patient's  mind,  or  be  made  by  an  external  cause;  only  in  the 
latter  case  is  it  correct,  so  far  as  strict  use  of  language  is  concerned,  to 
speak  of  an  impression.  The  belief  in  the  former  source  is  perpetuated 
in  the  term  ncevm  maternus,  while  almost  countless  illustrations  of  the 
alleged  power  of  the  latter  may  be  found  in  professional  literature. 
Dr.  Barker  has  called  attention  to  the  fact  that  three  of  the  most  dis- 
tinguished writers  of  fiction  in  modern  times — Goethe,  in  his  Elective 
Aj/inities  ;  Sir  Walter  Scott,  in  the  Fortunes  of  Nigel;  and  Dr.  Holmes, 
in  Elsie  Venner — "  have  based  incidents  on  this  belief,  in  a  way  which 
they  would  not  have  done  if  they  had  supposed  that  these  incidents 
would  be  rejected  by  their  readers  as  improbable."  It  may  be  added 
to  this  statement,  that  in  Redgauntlet,  Scott,2  not  so  much  by  the  inci- 
dent narrated  as  by  the  accompanying  footnote,  indicates  his  faith  in 
this  influence.3 

Quatrefages  said  it  has  been  long  observed  that  children  begotten  by 
a  man  when  intoxicated  often  permanently  present  the  characteristic 
signs  of  that  state — obtuse  senses  and  almost  entire  absence  of  intellect. 
The  remark  of  Diogenes  to  a  stupid  youth  is  well  known  :  "  Young 
man,  your  father  was  very  drunk  when  your  mother  conceived  you." 
If  the  temporary  state  of  the  progenitor  has  such  an  immediately 
powerful  and  permanent  influence  upon  the  germ,  it  is  not  probable 
that  the  evolution  of  that  germ  is  unaffected  by  the  mental  condition 
of  the  mother.  The  belief  in  maternal  impressions  has  that  criterion 
which  one  of  the  great  philosophers*  of  the  day  regards  as  indicating 
some  measure  of  truth — it  is  universal  and  perennial.  Though  prob- 
ably the  majority  of  physicians  are  either  very  skeptical  in  regard  to 
such  influence  or  absolutely  deny  it,  yet  there  is  a  large  number  of  emi- 
nent names  that  can  be  cited  as  believers  in  it.  Very  interesting  con- 
tributions to  the  subject  have  been  made  by  Drs.  Barker  and  Busey  in 
the  eleventh  volume  of  the  Transactions  of  the  American  Gynecological 
Society,  and  a  valuable  paper  upon  the  question  by  Dr.  Dabney  will  be 
found  in  the  first  volume  of  the  Encyclopaedia  of  Diseases  of  Children. 

There  is  not  space  for  even  an  imperfect  discussion  of  the  subject  in 
this  treatise,  and  I  shall  merely  adduce  a  few  of  many  illustrative  cases 

1  "  Up  to  the  beginning  of  the  eighteenth  century  physicians  adopted  the  opinion  of  Hippocrates, 
and  the  philosophers  admitted  with  Empedocles,  not  only  that  strong  emotions  experienced  by 
pregnant  women  could  cause  deformities  of  the  foetus,  but  also  the  desires  or  '  longings '  of  these 
women  cause  '  marks '  of  infants."— Bayard :  Annales  Medico-psychologiques,  tome  troisieme. 

2  Lilias,  in  conversation  with  her  brother,  Darsie,  exclaims  :  "  See,  brother,"  she  said,  pulling 
her  glove  off,   "  these  five  blood-specks  on  my  arm  are  a  mark  by  which  mysterious  Nature  has 
impressed  on  an  unborn  infant  a  record  of  its  father's  violent  death  and  its  mother's  miseries." 
Sir  Walter  Scott  adds  the  following  footnote  :  "  Several  persons  have  brought  down  to  these  days 
the  impressions  which  Nature  had  thus  recorded  when  they  were  yet  babes  unborn.    One  lady  of 
quality,  whose  father  was  long  under  sentence  of  death,  previous  to  the  rebellion,  was  marked  on 
the  back  of  the  neck  by  the  sign  of  a  broadaxe.    Another,  whose  kinsmen  had  been  slain  in  battle 
and  died  on  the  scaffold,  to  the  number  of  seven,  bore  a  child  spattered  on  the  right  shoulder  and 
down  the  arm  with  scarlet  drops,  as  if  of  blood.    Many  other  instances  might  be  quoted." 

3  The  Medical  Standard,  Chicago,  August,  1892,  adds  to  the  list    of    novelists  the  following 
names :  Dickens,  in  Barnaby  Rudge  ;  Read,  Put  Yourself  in  His  Place ;  and  Hawthorne,  Scarlet 
Letter. 

4  Herbert  Spencer:   First  Principles.    Elsewhere,  some  years  ago,  I  quoted  Lotze,  one  of  the 
most  eminent  German  philosophers  of  the  century,  as  believing  in  the  possibility  of  this  influence. 


THE  MANAGEMENT  OF  PREGNANCY.          223 

that  have  been  communicated  to  me,  and  which  have  never  been  pub- 
lished, suggesting  to  those  who  honestly  doubt  to  consult  the  papers  by 
Dr.  Meadows,1  Drs.  Barker  and  Busey,  and  by  Dr.  Dabney.  Those 
who  deny  maternal  impressions — of  course,  the  expression  is  used  to 
avoid  a  circumlocution — base  a  strong  and  unanswerable  argument 
upon  anatomical  and  physiological  grounds.  But  let  it  be  remembered, 
that  when  obstetric  auscultation  was  made  known,  two  of  the  most 
eminent  of  French  obstetricians — Duges  and  Baudelocque — denied  the 
possibility  of  hearing  the  foetal  heart  through  the  amnial  liquor,  the 
uterine  and  the  abdominal  wall,  and,  so  far  as  theoretical  argument  was 
concerned,  proved  their  thesis.  Those  who  believe  in  such  impressions, 
acknowledge  their  ignorance  of  the  way  in  which  these  impressions 
act ;  but  if  we  exclude  from  belief  all  that  we  do  not  understand,  our 
minds  will  be  kept  within  very  narrow  limits.2 

CASE  I. — Dr.  H.  Woodbury  Coleman,  of  Trenton,  N.  J.,  has  communicated  to 

me  the  following  history  of  a  case  under  his  own  observation:  "Mrs. ,  of 

this  city,  twenty-three  years  old,  and  about  two  months  pregnant,  was  one  day 
very  badly  frightened  by  her  son,  two  years  old,  nearly  cutting  off  with  a 
butcher-knife  his  left  thumb,  the  member  hanging  apparently  by  but  a  shred. 
She  was  without  any  one  to  assist  her,  and  dressed  the  injury  as  best  she  could. 
In  two  hours  I  saw  him,  and  she  assisted  me  in  that  and  subsequent  dressing. 
Her  mind  constantly  dwelt  on  the  accident,  and  in  due  time  she  gave  birth  to  a 
boy,  who,  to  my  great  surprise,  had  his  left  thumb  hanging  to  the  hand  by  a  thin 
pedicle  of  flesh." 

CASE  II. — I  am  indebted  also  to  Dr.  Coleman  for  the  following  case,  occurring 
under  the  observation  of  Dr.  Elias  March,  of  Paterson,  N.  J. :  "  In  1863  a  married 
private  in  the  army  came  home  on  forlough ;  his  left  arm  had  been  amputated 
near  the  shoulder-joint,  a  small  stump  remaining  which  had  not  yet  healed,  daily 
dressing  being  required,  which  was  done  by  his  wife  She  became  pregnant,  and 
during  the  early  part  of  her  pregnancy  her  thoughts  were  constantly  dwelling 
upon  the  condition  of  her  husband.  She  was  delivered  at  term  of  a  child  without 
any  left  arm,  only  a  small  fleshy  mass  attached  to  the  shoulder-joint,  resembling 
the  amputated  stump  observed  in  her  husband." 

CASE  III. — Dr.  W.  H.  Knipe,  while  a  student  at  Jefferson  Medical  College 
last  winter,  gave  me  the  following  statement  as  to  one  of  the  cases  of  confine- 
ment he  attended  in  connection  with  the  Philadelphia  Dispensary.  "Mrs.  A. 
W.,  primigravida,  burned  herself  with  a  poker  upon  the  wrist  of  her  right  hand, 
the  burn  being  in  a  line  with  the  index  finger ;  this  occurred  on  March  5th.  On 
the  7th  she  burned  herself  again,  but  on  the  wrist  of  her  left  hand.  She  was 
delivered  on  March  19th ;  the  chifd  was  a  girl,  and  had  on  each  wrist  marks  in 
the  same  location  and  presenting  the  general  characters  of  the  burns  upon  the 
mother's  wrists." 

CASE  IV. — One  of  the  students  of  Jefferson  Medical  College,  a  young  gentle- 
man whom  I  believe  perfectly  reliable,  showed  rne  a  varicose  left  popliteal  vein ; 
the  right  vein  was  quite  normal — indeed,  there  were  no  varicose  vessels  to  be 
found  except  that  mentioned.  From  his  mother  the  following  history  was  ob- 
tained. When  she  was  four  months  pregnant,  her  ninth  pregnancy,  she  was 
visited  one  day  by  a  woman  who  told  her  how  much  she  suffered  from  a  swollen 
vein  behind  the  left  knee,  and,  without  invitation,  at  once  exposed  it  to  her  view. 
She  was  quite  startled  by  the  sight,  and  expressed  her  sympathy  for  the  sufferer. 

1  Transactions  of  the  London  Obstetrical  Society,  vol.  viL 

2  In  Coleridge's  Table  Talk  it  is  stated  that  Dr.  Parr  said  to  a  person  who  asserted  he  would 
believe  nothing  he  could  not  understand  :  "  Then,  young  man,  your  creed  will  be  the  shortest  of 
any  man's  I  know." 

In  reference  to  this  very  question  a  famous  physiologist,  Burdach,  once  said  :  "If  we  wish  to 
deny  a  vital  phenomenon,  for  the  sole  reason  that  it  is  impossible  for  us  to  say  what  are  its  mate- 
rial conditions,  we  must  also  assert  that  it  is  impossible  for  any  quality  to  pass  from  the  grand- 
father to  the  grandson,  or  that  a  child  can  inherit  the  traits,  the  stature,  the  constitution,  the 
morbid  predispositions,  the  talents  and  inclinations  of  the  father." 


224  PHYSIOLOGY  OF  PREGNANCY. 

When  her  child  was  born  a  precisely  similar  condition  of  the  vein  behind  his 
left  knee  was  found,  and,  as  I  have  said,  has  continued  to  the  present.  To  these 
cases  I  add  the  following,  as  showing  a  possible  purely  psychical  influence  : 

CASE  V. — The  case  of  Benjamin  Hall  Blyth,  an  arithmetical  prodigy,  is  of 
interest  as  illustrating  the  possible  influence  of  maternal  impressions  in  produc- 
ing his  peculiar  gift.  His  mother,  while  pregnant  with  him,  witnessed  the 
wonderful  calculating  power  of  the  boy  Bidder,  once  publicly  and  twice  at  her 
home.  She  was  greatly  interested.  Blyth,  when  about  six  years  old,  one  day 
walking  with  his  father,  asked:  "At  what  hour  was  I  born?"  The  reply  was  4 
A.M.  He  then  asked:  "What  time  is  it  now?"  The  answer  was  7.50  A.M. 
Walking  on  a  few  hundred  yards,  he  turned  to  his  father  and  stated  the  exact 
number  of  seconds  he  had  lived. 

His  brother,  in  narrating1  this  incident,  adds  :  "  It  is,  I  believe,  admitted  by 
physiologists  that  anything  greatly  occupying  the  mother's  mind  certainly  may, 
and  frequently  does,  influence  the  character  of  her  unborn  child." 

The  five  cases  that  have  been  narrated  are  more  easily  explained  by 
the  hypothesis  of  maternal  impressions2  than  in  any  other  way.  An 
ancient  poet,  uttering  the  limited  knowledge  of  his  age,  declared  that  it 
was  not  known  how  the  bones  grew  in  the  womb  of  her  who  was  with 
child,  though  now  an  explanation  is  at  hand,  so  possibly  the  clearer 
light  of  future  science  may  make  plain  the  mystery  of  the  psychical, 
action  of  the  mother  upon  her  unborn  offspring. 

But  be  this  as  it  may,  it  is  not  wise  to  reject,  as  resting  upon  old 
wives'  fables,  an  opinion  avowed  by  such  men  as  Rokitansky,  Stoltz, 
Montgomery,  Tyler  Smith,  and  Meadows,  and  in  this  country  by  For- 
dyce  Barker,  Busey,  Spitzka,  and  Dabney. 

Conception  itself  presents  mysteries3  the  solution  of  which  will  prob- 
ably always  elude  the  research  of  man,  so  that  we  may  continue  with 
Harvey  to  admire  and  marvel  at  this  process.*  But  in  recognizing  the 
fact  that  the  foetus  may  be  affected  through  the  mother's  mind,  we  must 
beware  of  accepting  most  of  the  popular  evidence  given  in  its  favor; 
for  example,  a  child  is  born  with  a  deformity  which  the  mother  attrib- 
utes to  her  having  seen  a  similar  deformity  while  she  was  pregnant,  but 
upon  inquiry  it  is  ascertained  that  she  saw  it  after  the  stage  of  embryonic 
development  in  her  own  child  had  passed  when  its  deformity  resulted. 
Very  many  of  the  stories  of  the  influence  of  maternal  impressions  are 
absurd,5  carrying  with  them  their  own  contradiction,  and  are  often  sug- 
gested, or  even  fabricated  after  the  birth  of  the  child. 

In  addition  to  the  probable  but  occasional  coarser  proofs  of  the  in- 
fluence of  maternal  mental  impressions  upon  the  unborn  child,  as  shown 

1  Proceeding^  of  the  Society  for  Psychical  Research.    London,  July,  1892. 

*  "  The  singular  influence  thus  exerted  by  the  mind  of  the  mother  on  the  growth  of  the  foetus  is 
not  one  '  for  which,'  as  has  been  remarked  of  other  modes  of  action  of  the  mind  upon  the  body, 
1  It  is  likely  we  shall  ever  be  able  to  assign  a  reason,  or  which  it  would  be  any  great  hardship  to  be 
obliged  to  regard  as  an  ultimate  fact  in  physiology.'  " — Dr.  Alexander  Harvey,  op.  cit. 

8  "  Is  it  not  marvellous,"  says  Montaigne,  "  that  this  drop  of  seed  from  which  we  are  produced 
should  bear  the  impression  not  only  of  the  bodily  form,  but  even  of  the  thoughts  and  inclinations 
of  our  fathers?  Where  does  this  drop  of  water  keep  this  infinite  number  of  forms?  and  how  does 
it  bear  these  likenesses  through  a  progress  so  haphazard  and  so.  irregular  that  the  great-grandson 
shall  resemble  the  great-grandfather?"  Had  Montaigne  lived  after  the  important  discovery  made 
by  Ham,  he  would  have  substituted  spermatozoid  for  "drop  of  seed,"  and  declared  the  marvel 
vastly  greater. 

*  Bain  has  said  :    "  The  reproduction  of  each  living  being  from  one  or  two  others  through  the 
medium  of  a  small  globule  which  contains  in  itself  the  future  of  a  definite  species,  is  the  greatest 
marvel  in  the  whole  of  the  physical  world ;  it  is  the  acme  of  organic  complication." 

5  Of  course  there  have  been,  as  there  are  many  reported  cases  of  "  maternal  impressions  "  that 
only  amuse  by  their  absurdity.  Burton,  Anatomy  of  Melancholy,  has  mentioned  several.  Mon- 
taigne narrates  the  following :  "  There  was  presented  to  Charles,  the  emperor  and  king  of  Bohemia, 
a  girl  from  about  Pisa,  all  over  rough  and  covered  with  hair,  whom  her  mother  said  to  be  so  con- 
ceived by  reason  of  a  picture  of  St.  John  the'Baptist,  that  hung  within  the  curtains  of  her  bed." 


THE  MANAGEMENT  OF  PREGNANCY.  225 

in  monstrosities  and  in  deformities,  it  is  possible,  nay  probable,  that  very 
important  effects  are  produced  by  the  condition  of  the  mother's  mind 
in  pregnancy  which  belong  to  the  psychical1  rather  than  the  physical 
nature,  effects  that  are  gradually  made  manifest  in  childhood,  in  youth, 
and  in  adult  life.  It  not  unfrequently  happens  that  children  of  the 
same  parents  differ  very  greatly  in  mental  and  in  moral  qualities ;  they 
differ  in  the  power  of  acquiring  knowledge,  in  objects  of  desire  and  pur- 
suit, in  aptitudes  and  accomplishments.  In  some  instances  it  is  possible 
to  trace  a  probable  connection  between  these  differences,  and,  not  only 
the  condition  of  the  mother's  health  during  the  several  gestations  and 
the  surrounding  circumstances,  but  also  with  the  state  of  her  mind  dur- 
ing those  periods.  Here  is  opened  a  wide  field,  not  merely  for  speculation, 
but  for  actual  investigation.  And  the  more  the  whole  subject  of  human 
reproduction  is  studied  with  regard  to  the  physical  and  mental  health, 
and  the  happiness  and  usefulness  of  the  offspring,  the  more  grave  and 
solemn  the  responsibility  of  paternity  and  of  maternity  will  be  proved. 
Enough  is  known,  and  enough  has  been  said,  to  urge  the  importance  of 
the  pregnant  woman  living  as  far  as  possible  a  calm,  equable,  and  cheer- 
ful life,  avoiding  all  intense  emotion  and  all  great  excitement.2 

Weissmann,  in  a  lecture  upon3  "The  Supposed  Transmission  of  Mutilations," 
takes  the  ground  that  a  single  coincidence  of  an  idea  of  the  mother  with  an  ab- 
normality of  the  child  does  not  prove  a  causal  connection  between  the  phenomena. 
He  maintains  that  "  the  present  state  of  biological  science  teaches  us  that  with 
the  fusion  of  egg  and  germ-cell  potential  heredity  is  determined."  He  further 
asserts,  "  The  tales  of  the  efficacy  of  maternal  impressions,  and  of  the  transmis- 
sion of  mutilations  are  closely  connected,  and  break  down  before  the  present 
state  of  biological  science ;"  and  that  "  no  one  can  be  prevented  believing  such 
things,  but  they  have  no  right  to  be  looked  upon  as  scientific  facts,  or  even  as 
scientific  questions." 

F6re,4  incidentally  discussing  this  subject,  remarks :  "  The  acute  or  chronic 
emotions  of  the  mother  during  gestation  can  without  doubt  have  a  noxious 
influence  upon  the  child  in  causing  disorders  of  development,"  etc. 

THE  MEDICAL  CARE.  Under  this  head  it  is  proposed  to  consider 
briefly  some  of  the  most  frequent,  but  usually  minor,  disorders  of 
pregnancy  and  their  treatment. 

NAUSEA  AND  VOMITING.  The  gastric  irritability,  occurring  in  most 
cases  only  in  the  first  half  of  pregnancy,  is  usually  regarded  as  reflex. 
The  writer  quite  agrees  with  Vinay  in  considering  the  vomiting  of  preg- 
nancy as  the  type  of  nervous  vomiting,  and  presenting  greater  or  less 
intensity  according  to  the  condition  of  the  nervous  system.  When  we 
observe  cases  in  which  before  pregnancy  there  was  hysteric  cough  that 
is  superseded  by  vomiting,  when  patients  have  been  so  often  cured  by 
suggestion — some  trivial  application  to  the  cervix  proclaimed  as  infalli- 

1  In  a  paper  by  Dr.  Robert  J.  Lee,  entitled  "Maternal  Impressions,"  published  in  the  British 
Medical  Journal,  1875,  the  following  remark  is  made  :   "  It  would,  on  reflection,  appear  to  be  most 
natural  that  maternal  impressions  should  be  more  frequently  followed  by  some  unnatural  condition 
of  the  intellect  of  the  child  than  by  abnormalities  of  growth,  and  this  point  is  worthy  of  particular 
attention." 

2  Plato,  in  the  Seventh  Book  of  Laws,  after  speaking  of  the  susceptibility  of  the  newly  born 
infant  to  impressions,  remarks  :  "  Nay,  more,  if  I  were  not  afraid  of  appearing  to  be  ridiculous,  I 
would  say  that  a  woman  during  her  year  of  pregnancy  should  of  all  women  be  most  carefully 
tended,  and  kept  from  violent  or  excessive  pleasures  and  pains  ;  and  at  that  time  she  should  culti- 
vate gentleness,  and  benevolence,  and  kindness." 

'•'•  Lecture  before  the  Association  of  German  Naturalists,  Cologne,  1888. 
4  Revue  des  Deux  Mondes,  November  15, 1894. 

15 


226  PHYSIOLOGY  OF  PREGNANCY. 

ble,  \ve  must  believe  that  the  so-called  remedy  acted  only  by  mental  im- 
pression— and  also  other  sufferers  promptly  relieved  by  the  occurrence 
of  great  danger,  or  fear,  or  anxiety,  the  conclusion  seems  just  that  the 
disease  is  often  a  neurosis,  and  that  we  do  not  know  its  etiology,  simply 
hiding  our  ignorance  under  the  term  reflex. 

Nevertheless,  in  a  few  cases  an  obvious  uterine  cause,  either  uterine 
displacement  or  disease,  has  been  found. 

The  grave  form  of  the  disease  will  be  considered  in  the  Pathology  of 
Pregnancy,  and  there  will  now  only  be  presented  the  treatment  of  its 
milder  manifestations.  If  hygienic  means  should  fail,  such  as  taking 
the  morning  meal  in  bed,  iced  drinks,  lime-water  and  milk,  etc.,  a  com- 
plete change  of  scene,  if  possible,  may  prove  useful.  As  to  medical 
treatment,  the  means  that  have  been  advised  are  so  numerous  that  their 
recapitulation  would  occupy  too  much  space;  the  fact  of  their  being  so 
numerous  is  a  probable  proof  of  their  uncertainty  in  action.  Sir  James 
Y.  Simpson  strongly  recommended  oxalate  of  cerium,  5  to  10  grains  three 
or  four  times  a  day ;  now  the  valerianate  is  given  in  preference  to  the 
oxalate.  Dr.  Meigs  and  Dr.  Hodge  advised  tincture  of  aconite  root, 
two  drops  three  or  four  times  a  day.  Among  other  remedies  that  have 
been  employed  are  tincture  of  nux  vomica,  3  to  4  drops,  four  or  five  times 
a  day — this  sometimes  is  quite  useful — creosote,  hydrocyanic  acid,  bis- 
muth, wine  of  ipecacuanha,  opium  in  connection  with  belladonna,  mor- 
phia, hypodermatic  or  endermic,  chloral  and  potassic  bromide  by  the 
rectum,  and,  in  recent  years,  menthol,  antipyrin,  and  cocaine.  Counter- 
irritants  to  the  epigastrium,  ether-spray  to  the  epigastrium,  Chapman's 
ice-bag  to  the  spine,  galvanization,  and  faradization.  In  regard  to  the  use 
of  the  faradic  current,  the  following  are  the  directions1  of  Olivier :  one 
electrode  is  placed  at  the  lower  part  of  the  neck  posteriorly,  the  other 
upon  the  epigastric  region  ;  it  is  usual  to  have  the  upper  electrode  nega- 
tive, but  if  the  effect  is  not  satisfactory  the  poles  may  be  changed.  The 
application  lasts  two  to  three  minutes,  and  is  repeated  daily  or  once  in 
two  days.  Olivier  states  that  this  method  is  usually  rapidly  effective, 
also  saying  that  the  beneficial  result  may  be  from  a  doubtful  reflex  action, 
or  from  a  feeble  excitement  of  the  splanchnic  nerves,  or  be  purely  psy- 
chic ;  the  last  explanation  seems  the  most  probable. 

SALIVATION.  This  is  a  less  frequent  disorder  than  the  preceding, 
but  the  two  may  be  connected,  and  usually  are  when  either  is  severe. 
Washing  the  mouth  out  frequently  with  a  cold  astringent  solution  has 
been  commonly  recommended,  but  is  of  doubtful  value  in  a  severe  case. 
A  sudden  suppression  of  the  excessive  secretion  may  be  followed  by 
serious  consequences.  Baudelocque  refers  to  a  young  woman  who  in 
her  first  pregnancy  suffered  greatly  from  salivation,  but  was  refused  any 
means  for  its  relief;  in  her  second  pregnancy  the  same  symptom  re- 
curred, and  means  were  successfully  used  to  arrest  it,  but  the  day  fol- 
lowing she  died  of  apoplexy. 

Schramm2  has  reported  a  case  of  sialorrhoea  in  a  pregnant  woman  cured  by 
bromide  of  potassium,  after  the  use  of  iodide  of  potassium,  atropine,  galvaniza- 
tion of  the  sympathetic,  and  hypodermatic  injections  of  pilocarpine  without  any, 
or  only  temporary,  benefit. 

i  Hygiene  de  la  Grossesse.    Paris,  1892.  2  Berlin,  klin.  Wochen.,  1886. 


THE  MANAGEMENT  OF  PREGNANCY.  227 

CONSTIPATION.  If  this  cannot  be  prevented  by  suitable  diet,  an 
injection  of  a  pint  of  cool  water  may  be  used  each  morning.  If  medi- 
cines must  be  resorted  to,  they  should  be  mild  laxatives,  such  as  calcined 
magnesia,  compound  licorice  powder,  Seidlitz  powder,  Rochelle  salts,  the 
liquid  citrate  of  magnesia ;  a  few  prunes  that  have  been  stewed  in  an 
infusion  of  senna,  eaten  in  the  evening,  will  in  some  cases  prove  an  effi- 
cient means  of  removing  the  constipation ;  so  too  one  of  the  mild  ape- 
rient waters,  such  as  Huuyadi,  may  be  used.  All  drastic  purgatives 
should  be  avoided.  If  the  constipation  be  associated  with  hemorrhoids, 
Dr.  Fordyce  Barker1  advised  a  grain  of  aloes  made  into  a  pill  with  soap, 
hyoscyamus,  and  ipecacuanha  and  given  night  and  morning.  Cazin2 
commends  a  pill  containing  one  or  two  centigrammes  of  belladonna  given 
daily,  as  advised  by  Bretonneau. 

HEMORRHOIDS.  In  addition  to  correcting  constipation  by  the  means 
just  mentioned,  half  a  pint  of  cold  water  should  be  injected  into  the 
rectum  morning  and  evening,  the  injection  being  retained.  When  the 
piles  protrude  and  are  painful  they  may  be  bathed  with  warm  water 
and  laudanum,  or  the  ointment  of  galls  and  opium  may  be  applied. 
Dr.  Bartholow3  speaks  favorably  of  the  following  ointment,  advised  by 
Oesterlen,  for  hemorrhoids :  Pulv.  gallse,  3j  ;  pulv.  opii,  grs.  x ;  ung. 
plurnbi  subacetat.,  3ij  ;  ung.  simplicis,  5ij.  M-  The  protrusion  should 
be  reduced  as  soon  as  possible. 

(EDEMA  OF  THE  LEGS — VARICES.  The  former  is  in  many  cases  a 
consequence  of  the  latter.  It  usually  disappears  after  lying  down  for  a 
time,  and  is  to  be  treated  by  position,  by  removing  all  constriction,  as 
from  garters,  and  by  bathing  with  cool  water.  Varices,  according  to 
Budin,  occur  in  twenty  to  thirty  per  cent,  of  pregnant  women ;  but  in 
many  cases  the  dilatation  of  veins  must  be  very  slight  if  there  be  so 
large  a  percentage ;  my  own  observation  leads  me  to  believe  that  only 
from  five  to  ten  per  cent,  of  women  are  thus  affected  in  pregnancy. 
Varices  of  the  lower  limbs  are  treated  by  position  and  compression. 
Cazin4  advises  the  application  first  of  an  old  linen  bandage,  and  over 
this  one  of  flannel  extending  from  the  toes  to  a  point  above  the  enlarged 
vessels.  Some  prefer  an  elastic  stocking,  but  a  flannel  bandage  is  less 
expensive,  and  properly  applied^more  comfortable.  It  is  to  be  remem- 
bered that  too  great  compression  has  caused  abortion.  An  accident  to 
which  the  patient  is  liable,  either  from  violent  scratching,  from  a  blow, 
or  sometimes  simply  from  the  pressure  of  the  column  of  blood  in  un- 
supported vessels,  is  a  rupture  of  one  of  them,  permitting  a  hemorrhage 
rapidly  fatal  if  the  flow  be  not  promptly  arrested.  The  patient  is  in- 
formed of  this  danger,  and  told,  if  the  accident  occur,  to  lie  down  at 
once  and  stop  the  flow  by  firmly  pressing  her  finger  upon  the  bleeding 
point. 

PRURITUS  OF  THE  VULVA.  Itching  of  the  vulva  is  a  symptom  of 
various  conditions,  such  as  oedema,  follicular  inflammation,  eczema, 
herpes,  or  prurigo,  etc.  It  is  not  remarkable  that  the  external  genera- 
tive organs,  sharing  in  the  increased  supply  of  blood  occurring  in  preg- 
nancy, and  in  some  cases  the  seat  of  passive  congestion  caused  by  the 

1  Puerperal  Diseases.  2  Archives  de  Tocologie,  1881. 

3  Materia  Medica  and  Therapeutics.  <  Op.  cit. 


228  PHYSIOLOGY  OF  PREGNANCY. 

enlarged  uterus,  should  be  liable  to  some  of  the  local  affections  men- 
tioned, and  which  have  as  their  most  prominent  symptoms  a  more  or 
less  intense  itching.  The  violent  rubbing  and  scratching  which  the 
pruritus  may  cause  of  course  aggravate  the  disease.  The  irritation 
sometimes  extends  to  the  vagina,  but  it  usually  occupies  only  the  great 
and  less  lips.  The  vulval  inflammation  from  which  the  pruritus  results 
may  be  caused  by  a  vaginal  discharge. 

The  suffering  of  some  pregnant  women  from  pruritus  is  often  very 
great.  Dewees  has  spoken  of  a  woman  under  his  charge  thus  afflicted, 
who  was  confined  to  her  room  during  three  months  of  her  gestation, 
and  whose  only  relief  in  her  entire  period  was  had  by  the  nearly  con- 
stant application  of  ice- water. 

He  also  described  an  aphthous  eruption  as  present  in  some  cases,  and 
for  this  he  advised  a  strong  solution  of  borax  ;  it  may  be  used  for  bath- 
ing the  vulva,  and  also  for  injecting  in  the  vagina,  and  frequently  proves 
quite  beneficial. 

Some  patients  find  relief  of  the  itching  by  applying  to  the  vulva 
cloths  wrung  out  of  hot  water. 

Dr.  Tauszky  recommends  the  application  with  a  brush  to  the  affected 
parts  eight  or  ten  times  a  day  of  the  following  solution,  first  sug- 
gested by  Hufeland :  two  drachms  of  powdered  gum-arabic,  one  of 
balsam  of  Peru,  one  and  a  half  of  oil  of  almonds,  and  one  ounce  of 
rose-water. 

Bulkley  advises  an  ointment,  made  by  rubbing  together  one  drachm 
each  of  camphor  and  chloral,  and  then  incorporating  the  mixture  with 
eight  ounces  of  ointment  of  rose-water.  Doubtless  cocaine  ointment  or 
solution  would  prove  useful.  Spiegelberg  found  the  most  reliable  rem- 
edy a  solution  of  corrosive  sublimate,  applied  1  to  3  times  (1  : 100-200 
parts  of  dilute  alcohol),  followed  by  the  application  of  tar- water,  and  by 
chamomile  hip-baths.  Tarnier  also  prefers  a  solution  of  corrosive  sub- 
limate, 2  parts ;  alcohol,  10  parts ;  rose-water,  40  parts ;  and  distilled 
water,  450  parts.  This  lotion  is  employed  undiluted  morning  and 
evening. 

But,  as  observed  by  Olivier,1  if  the  parts  are  inflamed,  in  some 
subjects  mercurial  lotions  cause  great  suffering.  He  also  states  that  in 
a  series  of  cases  he  has  had  prompt  success  from  the  lotion  of  Del- 
peyrou,  which  is  composed  of  hydrate  of  chloral,  boric  acid,  glycerin, 
alcohol,  and  water.  Unfortunately  the  formula  for  this  lotion  is  not 
given,  and  Mr.  Morgan,  a  prominent  pharmaceutist  of  this  city,  sug- 
gests the  following  :' Chloral,  2  drachms;  glycerin,  4  drachms;  alcohol, 
4  drachms;  boric  acid,  1  drachm ;  and  to  these  sufficient  water  is  added 
to  make  four  ounces.  The  parts  are  first  washed  in  water  as  hot  as 
can  be  borne,  and  then  the  lotion,  diluted  with  an  equal  quantity  of 
water,  is  applied  by  absorbent  cotton ;  a  thin  layer  of  cotton,  after  being 
dipped  in  the  solution,  is  interposed  between  the  labia.  The  application 
may  be  made  two  or  three  times  a  day. 

HERPES  GESTATIONIS.  Bulkley  has  described  this  affection  as  begin- 
ning with  clusters  of  vesicles  upon  the  extremities,  whence  extension  to 

.     i  Op.  cit. 


THE  MANAGEMENT  OF  PREGNANCY.  229 

the  trunk  occurs.  The  disease  does  not  disappear  until  after  labor,  and 
may  recur  in  subsequent  pregnancies;  the  treatment  does  not  differ  from 
that  usually  required  by  herpes. 

GENERAL,  PRURITUS.  This,  like  the  last,  is  a  comparatively  rare 
affection.  It  is  characterized  by  intense  itching  of  the  skin,  without 
any  eruption  being  present  to  explain  it.  In  a  case  narrated  by  Spiegel- 
berg  the  pruritus  began  in  the  second  month  of  pregnancy,  and  lasted 
until  labor,  being  only  partially  relieved  by  Fowler's  solution.  Stoltz 
gives  two  cases.  Probably  arsenic  or  sulphur  internally,  and  alkaline 
or  mercurial  lotions,  may  effect  slight  mitigation  in  some  cases.  The 
affection  may  be  so  serious,  depriving  the  patient  of  rest,  and  causing 
such  rapid  deterioration  of  health  and  so  great  emaciation,  that  the 
question  of  ending  the  pregnancy  is  presented. 

NEURALGIA.  This  is  more  frequent  in  pregnancy  than  in  the  non- 
pregnant  state,  and  may  require  the  administration  of  tonics,  especially 
of  quinine  and  iron,  and  the  use  of  anaesthetics  locally ;  in  some  instances 
the  suffering  demands  morphine  hypodermatically,  but  usually  phenacetin 
or  antipyrin  will  relieve.  Odontalgia  is  so  common  in  pregnant  women 
and  the  pain  may  be  so  severe  that  extraction  of  an  offending  tooth  is 
too  often  done,  and  hence  the  familiar  adage,  "for  every  child  a  tooth." 
Marshall  states1  that  softening  of  the  dentine  is  not  uncommon  in  preg- 
nancy, and  caries  may  result.  He  holds  that  long,  tedious  operations, 
like  the  restoration  of  form  in  decayed  teeth  with  gold,  are  inadmissible 
during  gestation.  "  All  operations  upon  the  teeth  at  such  times  should 
be  as  free  from  pain  and  fatigue  as  is  possible,  from  the  fact  that  in 
certain  cases  miscarriage  might  be  the  result."  He  advises  as  means 
preventive  of  caries  a  thorough  and  frequent  use  of  the  toothbrush  and 
floss  silk  at  least  three  times  a  day,  supplemented  by  tooth-powders  and 
antacid  mouth-washes. 

GINGIVITIS.  Pinard  first  drew  attention  to  gingivitis  in  pregnant 
women.  This  affection  is  characterized  by  redness  and  swelling  of  the 
gums,  more  especially  of  the  anterior  maxillary  bones — indeed,  in  the 
vicinity  of  the  molars  the  disease  does  not  appear ;  the  swollen  parts 
readily  bleed  upon  touch,  and  the  corresponding  teeth  may  become  quite 
loose.  Gingivitis  is  manifested  about  the  fourth  month  of  gestation, 
and  having  once  appeared  does  not  entirely  go  away  until  after  the 
pregnancy  ends. 

The  treatment  consists  in  the  thorough  cleansing  of  the  teeth,  the 
removal  of  tartar,  and  the  diligent  use  of  the  tooth-brush.  Should 
these  means  fail,  the  use  of  astringents,  such  as  tincture  of  myrrh  and 
water,  would  be  indicated.  Tincture  of  iodine  locally  used  has  been 
recommended.  Pinard  advises  applying  to  the  diseased  gums  a  solu- 
tion of  equal  quantities  of  hydrate  of  chloral  and  tincture  of  cochlearia, 
the  application  being  made  every  day  or  once  in  two  days. 

SLEEPLESSNESS.  If  this  cannot  be  remedied  by  hygienic  means — 
such  as  taking  only  alight  supper,  exercise  in  the  open  air,  and  a  sponge- 
bath  before  retiring — and  if  caused  by  no  obvious  physical  disorder  which 
can  be  corrected,  one  of  the  alkaline  bromides  may  first  be  tried  alone, 

1  Journal  of  the  American  Medical  Association,  February  22,  1890. 


230  PHYSIOLOGY  OF  PREGNANCY. 

and  should  this  fail  chloral  may  be  combined  with  it.  Opium  is  in  some 
cases  necessary,  but  great  care  must  be  takeu  that  it  is  not  given  so  fre- 
quently the  habit  of  using  it  is  formed.  \ 

The  obstetrician  will  visit  the  pregnant  woman  from  time  to  time, 
especially  during  the  latter  weeks  of  gestation,  so  that  he  may  know 
her  condition  is  favorable  for  her  approaching  trial.  Once  a  week, 
during  the  last  two  or  three  months  of  gestation,  the  urine  should  be 
examined  with  reference  to  possible  albuminuria ;  the  examination  must 
be  made  earlier  if  any  symptoms,  hereafter  to  be  mentioned,  indicate 
the  probability  of  this  disorder  being  present. 

Few  women,  if  a  proper  explanation  be  given,  will  object  to  an  ex- 
ternal examination  made  in  pregnancy  for  obstetric  diagnosis.  Certainly 
such  examination  is  advisable  in  most  cases ;  and  in  some,  if  there  is 
the  least  suspicion  of  an  unfavorable  presentation,  must  be  insisted  upon. 
Moreover,  if  the  history  of  previous  labors  indicates  any  pelvic  deform- 
ity, or  there  may  be  other  reasons  for  suspecting  such  condition,  the 
examination  must  be  not  only  external  but  also  internal. 

In  lying-in  institutions  careful  pelvic  measurements  are  made  in  the  case  of  a 
pregnant  woman,  and  hence  when  serious  deviations  from  the  normal  are  dis- 
co Yerecl  in  time,  appropriate  means  to  avert  danger  to  mother  and  child  are  taken. 
The  pregnant  woman  in  private  practice,  and  her  unborn  child,  are  entitled  to 
quite  as  great  prophylactic  care.  I  know  that  occasionally  a  mother  perishes  in 
labor,  and  her  child,  too,  because  of  the  failure  of  the  obstetric  attendant  to  know 
in  time  the  existence  of  a  pelvic  deformity. 


SECTION  II. 
THE  PHYSIOLOGY  OF  LABOR 


CHAPTER   X. 

CAUSES  OF  LABOR — PRECURSORY  SYMPTOMS — PHYSIOLOGICAL  PHE- 
NOMENA— CHANGES  IN  THE  FORM  OF  THE  HEAD  IN  VERTEX 
PRESENTATION — CAPUT  SUCCEDANEUM. 

LABOR,  the  physiological  end  of  pregnancy,  is  the  process  by  which 
the  foetus  and  its  appendages  are  separated  from  the  mother ;  it  is 
travail,  bringing  forth.  Nature's  design  being  the  continuance  of  the 
race,  the  foetus  must  have  reached  such  development  before  its  expul- 
sion as  to  be  viable,  that  is,  capable  of  living  external  to  the  mother. 
If,  therefore,  the  product  of  conception  be  expelled  before  such  capa- 
bility, the  process  is  not  called  labor,  but  abortion  or  miscarriage.  If 
labor  takes  place  in  the  eighth  or  ninth  month,  it  is  called  premature, 
because  the  foetus  has  not  attained  its  perfect  development;  if  labor 
be  deferred  beyond  nine  months,  it  is  called  postponed  or  delayed,  if 
the  foetus  is  alive,  but  missed  labor  if  it  is  dead.  When  parturition  is 
effected  by  the  sole  power  of  the  maternal  organism  it  is  called  natural; 
but  if  art  aid  or  replace  that  power.,  it  is  termed  artificial  labor.  In 
order  that  a  labor  may  be  natural  the  foetus  must  not  exceed  the  normal 
size  and  the  presentation  must  be  favorable ;  the  birth-canal  must  be 
typical  in  size  and  form  ;  and,  finally,  the  forces,  voluntary  and  involun- 
tary, of  the  mother  must  be  able  to  dilate  the  birth-canal,  mould  the 
presenting  part,  determine  changes  in  its  position  so  that  shorter  foetal 
diameters  are  brought  in  relation  with  longer  diameters  of  the  mother's 
pelvis,  the  passenger  thus  accommodated  to  the  passage,  and  all  resist- 
ance overcome. 

DETERMINING  CAUSES  OF  LABOR.  For  a  long  time  it  was  believed 
that  the  foetus  escaped  from  the  uterus  by  its  own  efforts,  just  as  the 
chick  leaves  its  shell,  or  the  butterfly  its  cocoon.  Harvey,  for  example, 
held  that  "  the  foetus,  with  its  head  downward,  attacks  the  portals  of  the 
womb,  opens  them  by  its  own  energies,  and  thus  struggles  into  day." 

If  the  foetus  made  its  own  way  from  the  mother's  womb,  the  question  naturally 
arose  as  to  the  reason  for  its  action,  and  various  answers  were  given.  The  amniotic 
liquor  became  acrid,  and  irritated  the  skin  of  the  foetus ;  Drelincourt  said  that  the 
intestine  was  filled  with  meconium,  and  hence  a  colic  which  disturbed  the  foetus, 
and  made  it  strive  to  get  out,  while  others  held  that  a  distended  bladder  was.  the 
cause  of  this  effort ;  the  womb  became  too  hot  for  it,  or  it  needed  to  breathe,  or 


232  PHYSIOLOGY  OF  LABOE. 

sought  different  food ;  Fabricius  asserted  that  the  weight  of  its  head  pressed  open 
the  mouth  of  the  iiterus.  Some  thought  that  obliteration  of  the  utero-placental 
vessels  caused  the  child  to  leave,  others  that  the  uterus  having  reached  a  certain 
distention,  reacted  and  by  its  contraction  incommoded  the  foetus ;  narrowing  of 
the  ductus  arteriosus,  of  the  ductus  venosus,  and  of  the  foramen  of  Botal  have 
also  been  suggested  as  the  causes  of  the  action  of  the  fcetus. 

Those  who  believed  that  the  foetus  was  an  active  agent  in  parturition 
asserted  that  the  delivery  of  a  dead  child  was  more  difficult  than  that 
of  a  living  one.  Admitting  the  assumption,  Depaul  has  suggested  three 
answers  :  First,  the  living  foetus  by  its  movements  may  excite  or  increase 
uterine  contractions.  Second,  in  case  the  foetus  dies,  some  time  may 
elapse  between  the  death  and  the  expulsion,  but  the  development  of  the 
uterus  ceasing  with  the  former,  its  action  in  the  latter  may  be  less  power- 
ful than  it  is  at  the  time  of  perfect  development.  Third,  if  the  mem- 
branes have  been  ruptured,  the  following  foetal  decomposition  may  have 
a  poisonous  influence  upon  the  muscular  fibres  of  the  uterus,  weakening 
their  action. 

Post-mortem  births  have  been  claimed  as  proof  that  the  foetus  could 
escape  from  the  womb  by  its  own  efforts.  But  when  these  happen  soon 
after  death  they  result  from  the  persistence  of  uterine  contractility, 
while  the  resistance  of  soft  parts  is  lost ;  occurring  later,  they  are  caused 
by  the  pressure  of  gases  formed  in  the  abdomen  external  to  the  uterus. 

Fatty  degeneration  of  the  decidua,  by  which  the  ovum  is  detached 
from  the  uterus  and  becomes  a  foreign  body,  is  alleged  by  some  to  be  the 
cause  of  labor.  It  is  well  known  that  artificial  detachment  of  the  ovum 
is  one  of  the  most  certain  methods  of  inducing  labor.  But  the  fatty 
degeneration  which  is  supposed  to  excite  natural  labor  is  not  a  constant 
fact. 

The  influence  of  the  ovaries  in  exciting  labor  has  been  maintained. 
Tyler  Smith  believed  he  had  established  that  ovarian  excitement  is  the 
law  of  parturition  in  all  forms  of  ovi-expulsion ;  this  excitement,  this 
nisus,  he  alleged,  is  active  at  mon£hly  periods  through  the  pregnancy, 
becoming  at  the  tenth  so  great  as  to  cause  labor.  Probably  the  majority 
of  women  are  not  conscious  during  their  pregnancy  of  periodical  ovarian 
disturbance;  in  the  order  of  nature  ovulation  is  then  suspended,  the 
ovaries,  for  the  time  being  having  fulfilled  their  work,  now  rest.  Besides, 
the  tenth  period  varies  in  different  women  ;  in  one  menstruating  every 
thirty  days  it  is  three  hundred  days,  while  in  another  who  has  her  flow 
every  twenty  days,  it  is  only  two  hundred.  Again,  women  may  con- 
ceive who  never  menstruated,  or  in  the  physiological  absence  of  the  flow 
during  lactation ;  a  nisus  which  fails  to  cause  menstruation  in  the  non- 
pregnant  state  has  not  enough  power  to  start  the  machinery  of  child- 
birth. Single  ovariotomy  has  frequently  been  done  during  pregnancy, 
and  labor  occurred  at  the  normal  time.  Double  ovariotomy  has  been 
done  in  a  few  cases  in  pregnant  women,  but  this  did  not  delay  or  pre- 
vent the  action  of  the  uterus  occurring  at  the  normal  end  of  gestation. 

But  if  the  determining  cause  of  labor  be  not  found  in  the  foetus  or 
in  changes  in  the  decidua  or  in  the  ovaries,  may  it  not  be  in  the  uterus? 
It  is  held  by  some  that  when  the  muscular  fibres  of  the  uterus  have 
attained  their  perfect  development,  expulsive  contractions  result.  But 


CAUSES  OF  LABOR.  233 

the  contractile  power  of  the  uterus  is  manifested  in  premature  labor  and 
in  abortion.  Others  teach  that  the  uterus  may  be  distended  to  a  certain 
degree,  and  then  reacts  against  the  distention.  But  the  thickness  of 
the  uterine  walls  is  different  in  different  subjects,  and  in  the  same  sub- 
ject varies  in  different  pregnancies,  yet  in  each  case  the  reaction  occurs 
just  when  the  fcetus  has  reached  maturity.  In  plural  pregnancy  and 
also  in  polyhydramnios  the  uterine  distention  is  greater  than  in  single 
or  in  normal  pregnancy. 

Brown-Sequard  has  shown  that  carbonic  acid  circulating  in  increased 
quantity  in  the  blood  of  a  pregnant  animal  causes  uterine  contractions, 
and  the  occurrence  of  labor  is  therefore  attributed  to  the  accumulation 
of  carbonic  acid  in  the  venous  apparatus  of  the  uterus.  Dr.  Robert 
Barnes1  has  called  attention  to  the  fact  that  when  the  French  army  in 
Algeria  kindled  fires  at  the  mouths  of  caves  in  which,  among  others,  a 
number  of  pregnant  women  had  taken  refuge,  almost  all  these  women 
miscarried.  But  it  is  possible  that  mental  emotion  had  as  much  to 
do  with  the  accident  as  carbonic  acid.  The  carbonic  acid  hypothesis 
of  the  induction  of  labor  fails,  because  it  does  not  explain  why  the 
uterine  muscular  tissue  did  not  act  sooner,  but  was  indifferent  to  the 
presence  of  carbonic  acid  until  nine  months  ended,  and  then  suddenly 
resented  and  began  the  process  of  labor. 

Leopold  finds  the  source  of  the  irritation  which  leads  to  uterine  con- 
tractions in  the  increased  venosity  of  the  blood  in  the  maternal  or  foetal 
placenta,  resulting  in  venous  thromboses  of  the  serotina  or  in  the  uterine 
walls. 

Dubois  and  Depaul  upheld  a  theory  first  advanced  by  Power  in  1819. 
According  to  it,  the  expulsion  of  the  fetus  is  similar  to  that  of  the 
feces  or  of  the  urine.  Feces  accumulate  in  the  rectum,  and  after  a  time 
by  pressure  on  the  sphincter  irritate  it,  until  reflex  action  determines 
contractions  which  overcome  its  resistance,  and  the  bowel  is  emptied. 
So,  too,  the  renal  secretion  does  not  at  first  excite  vesical  contractions ; 
but  when  the  reservoir  is  more  or  less  completely  filled  the  fibres  of  the 
neck  are  stretched,  causing  irritation  and  dragging  on  the  sphincter  of 
the  organ,  and  this  sensation  reacting  upon  the  body,  contraction  is 
excited  and  its  contents  discharged.  In  pregnancy  the  upper  part  of 
the  uterus  is  developed  first ;  "  little  by  little  the  lower  segment  takes 
part  in  the  general  development  of  the  organ,  and  the  ovum  gradually 
occupies  a  larger  space  in  this  portion ;  thus  at  the  ninth  month  that 
section  of  the  uterus  adjoining  the  internal  orifice  of  the  neck  is 
developed  in  turn,  and  causes  stretching  of  the  circular  fibres  ;  this 
purely  mechanical  irritation,  by  reflex  influence,  acts  upon  the  upper 
part  of  the  womb."2 

But,  as  frankly  acknowledged  by  Depaul,  the  theory  of  Power  fails 
to  explain  the  access  of  labor-pains  in  extra-uterine  pregnancy. 

1  Transactions  of  the  American  Gynecological  Society,  vol.  i. 

*  Depaul,  op.  cit.  Garimond,  Nouv.  Arch.  d'Obst4t.  et  de  Gyn6col.,  1887,  in  a  study  of  the 
determining  cause  of  labor,  referring  to  the  analogy  between  the  expulsive  exertion  action  of  the 
bladder  and  that  of  the  uterus,  observes  that  it  is  not  irritation  of  the  sphincter,  but  excessive 
tension  of  the  entire  cavity  of  the  bladder  that  causes  this  organ  to  contract,  expelling  its  con- 
tents ;  and  thus  in  regard  to  the  uterus  :  tension  of  the  uterine  walls  is  the  cause  of  uterine  action 
beginning,  and  contractions  occur,  not  in  response  to  an  elective  sensibility  seated  in  the  body 
or  neck,  but  this  sensation  belongs  to  the  entire  physiological  organ.  This  is  simply  an  old 
hypothesis  in  new  clothes. 


234  PHYSIOLOGY  OF  LABOR. 

Ahlfeld1  regards  the  irritation  which  determines  uterine  activity  as 
primarily  originating  in  the  lower  uterine  segment  and  cervix.  These 
are  greatly  stretched  at  the  end  of  pregnancy.  Moreover,  the  parts  of 
the  birth-canal  adjacent  are  rich  in  nerves,  and  especially  at  the  ante- 
rior and  lateral  periphery  of  the  cervix  large  numbers  of  ganglia  cells 
are  found.  He  refers  to  the  inaugural  dissertation  of  Kniipfer,  at  the 
Dorpat  Klinik,  1892,  in  which  careful  study  of  the  bat  has  proved  the 
existence  of  vast  numbers  of  ganglia  cells  in  the  peri-cervical  tissue, 
irritation  of  which  caused  expansion  of  the  lower  uterine  segment. 

Some  writers,  plainly  seeing  the  weakness  of  each  of  the  various 
causes  adduced  as  determining  labor,  have  rested  their  explanation  in  a 
combination  of  them.2  It  is  better  to  refer  the  matter  to  a  law  of  the 
organism,  a  law  the  cause  of  which  we  do  not  know,  for,  as  truly  said 
by  Foster,3  we  are  utterly  in  the  dark  as  to  why  the  uterus,  after 
remaining  apparently  perfectly  quiescent,  or  with  contractions  so  slight 
as  to  be  with  difficulty  appreciated  for  months,  is  suddenly  thrown  into 
action,  and  within,  it  may  be,  a  few  hours  gets  rid  of  the  burden  it  has 
borne  with  such  tolerance  for  so  long  a  time  ;  indeed,  none  of  the 
various  hypotheses  which  have  been  put  forward  can  be  considered 
satisfactory. 

THE  EFFICIENT  CAUSES  OF  LABOR.  The  chief  agent  in  the  expul- 
sion of  the  foetus  is  the  uterus  itself.  During  the  first  part  of  labor  the 
uterine  contractions  act  unaided  ;  but  when  the  os  uteri  is  dilated  so  as 
to  oifer  little  or  no  resistance  to  the  descent  of  the  part  of  the  foetus 
which  presents,  they  are  reinforced  by  the  action  of  the  abdominal 
muscles.  In  exceptional  cases,  as  in  complete  prolapse  of  the  uterus,  or 
when  the  patient  is  paraplegic,  or  profoundly  narcotized,  uterine  con- 
tractions have  alone  effected  delivery,  but  the  labor  under  these  cir- 
cumstances is,  as  a  rule,  longer. 

PRECURSORS  OF  LABOR.  In  some  cases  labor  begins  abruptly — the 
patient,  for  example,  being  wakened  in  the  night  by  frequent  and  strong 
uterine  contractions.  But  in  the  majority  a  change  in  the  form  of  the 
abdomen,  increased  secretion  from  the  external  organs  of  generation  at 
first,  and  then  from  the  glands  of  the  neck  of  the  uterus,  swelling  of 
the  labia,  aud  the  hitherto  painless  contractions  of  pregnancy  becoming 
more  frequent  and  causing  some  discomfort,  prepare  the  way  and 
herald  the  coming  of  labor.  The  first  of  these  phenomena  is  not  con- 
stant ;  it  results  from  the  head  of  the  foetus  covered  by  the  inferior 
segment  of  the  uterus  and  more  or  less  of  the  expanded  upper  portion 
of  the  cervical  canal  entering  the  pelvic  cavity,  while  the  superior  por- 
tion of  the  uterus  inclines  more  in  front  and  is  lower.  By  this  descent 
or  settling  down  of  the  uterus — falling  of  the  abdomen  it  is  sometimes 
called — the  patient's  waist  is  not  so  large,  her  breathing  is  less  interfered 
with,  she  can  take  a  fuller  inspiration,  aud  her  stomach,  relieved  from 
pressure,  receives  more  food  ;  on  the  other  hand,  the  increased  downward 
pressure  may  cause  irritability  of  the  bladder  or  of  the  rectum,  difficulty 

1  Lehrbuch  der  Geburtshilfe,  1894. 

-  Their  explanation  has  always  seemed  to  me  similar  to  the  statement  of  the  physician  who 
combined  many  medicines  in  his  prescription,  "  so  that  the  disease  might  take  whichever  it 
liked." 

8  Text-book  of  Physiology. 


STAGES  OF  LABOR.  235 

in  walking,  and  greater  swelling  of  the  lower  limbs.  This  change  in 
the  form  of  the  abdomen  is  marked  in  the  primigravida,  but  may  fail 
in  the  multigravida,  for  the  uterus  and  the  abdominal  wall  of  the  latter 
having  undergone  development  in  one  or  more  previous  pregnancies,  yield 
more  readily,  the  uterus  does  not  rise  so  high,  and  is  more  inclined  for- 
ward earlier  in  pregnancy.  In  cases  presenting  this  phenomenon1  its 
value  as  a  sign  of  approaching  labor  is  not  great,  for  while  it  usually 
occurs  from  one  to  two  weeks  before,  this  interval  may  be  only  a  day  or 
two,  or  it  may  be  a  month.  It  is  a  favorable  indication  as  to  the  labor, 
for  it  shows  that  the  presentation  is  normal  and  the  pelvis  roomy. 

Active  hypera3mia  and  passive  congestion,  the  latter  resulting  from 
pressure,  cause  more  abundant  secretion  from  the  glands  of  the  cervix. 
This  discharge  is  viscid,  yellowish,  and  in  some  cases  toward  the  end  of 
pregnancy  contains  stria?  of  blood ;  when  thus  stained,  its  color  being 
caused  in  the  same  manner  as  that  of  the  sputa  in  pneumonia  according 
to  Velpeau,  it  is  known  in  the  lying-in  room  as  a  u  show,"  and  is  then 
usually  an  indication  of  considerable  advance  in  labor.  It  is  caused, 
whether  occurring  at  the  end  of  pregnancy  or  in  the  beginning  of  labor, 
by  partial  detachment  of  the  decidua  near  the  mouth  of  the  womb.  The 
strise  of  blood  observed  at  the  close  of  the  stage  of  dilatation  of  the  os 
uteri  result  from  slight  lacerations  of  the  cervix.  An  abundant  dis- 
charge from  the  cervical  glands  is  a  favorable  indication  as  to  the  ready 
dilatation  of  the  os  uteri. 

The  external  organs  of  generation  are  swelled  and  moistened  by  their 
own  aud  by  the  vaginal  secretions.  The  painless  uterine  contractions 
of  pregnancy  become  more  frequent,  and  begin  to  cause  more  or  less 
discomfort.  In  the  parous  especially  it  is  not  unusual  for  these  contrac- 
tions to  become  decidedly  painful  some  days  before  labor ;  they  may 
come  on  at  night  disturbing  the  woman's  rest,  and  making  her  believe 
labor  is  at  hand,  but  disappear  in  the  morning  to  be  renewed  the  follow- 
ing night.  When  the  cervix  is  effaced,  and  uterine  contractions  recur 
at  regular  intervals  and  cause  dilatation  of  the  os  uteri,  labor  has  begun. 

STAGES  OF  LABOR.  Although  labor  is  one  process  from  the  begin- 
ning to  the  end,  yet  it  is  usual  to  consider  it  as  including  three  stages 
or  periods.  The  first  stage,  the  uterine  period,  begins  with  dilatation 
of  the  os  uteri,  and  ends  when  that  dilatation  is  so  complete  that  the 
head,  or  the  greater  part  of  it,  can  pass  through  the  os  uteri.  The 
second  stage  of  labor,  the  utero-abdominal  period,  then  begins,  and 
includes  the  expulsion  of  the  child.  The  third  stage,  the  placeutal 
period,  embraces  the  detachment  of  the  placenta,  its  expulsion  from 
the  uterus,  and  then  from  the  vagina.  While  the  boundary  between  the 
second  and  third  stages  is  well  marked,  that  between  the  second  and  the 
first  is  by  no  means  so  clear;  theoretically,  the  line  is  as  stated,  but  in 
practice  one  rarely  sees  it  so  sharply  and  abruptly  defined — the  first 
oftener  gradually  passes  into  the  second  stage. 

1  According  to  the  investigations  of  Brill,  in  primigravidse  the  greatest  circumference  of  the 
foetal  head  was  found  to  have  passed  the  brim  at  the  end  of  pregnancy  in  half  the  cases,  but 
in  multigravidse  in  one-fourth  only ;  if  the  true  conjugate  is  less  than  10  centimetres,  in  only 
one-third. 

Prof.  Muller,  of  Berne,  directs  in  those  cases  in  which  the  head  has  not  thus  passed  the  brim  at 
the  end  of  pregnancy,  to  grasp  the  fretus  through  the  abdominal  wall  and  force  the  head  as  far  as 
possible  into  the  pelvic  canal. 


236  PHYSIOLOGY  OF  LABOR. 

PHENOMENA  OF  LABOR.  These  are  usually  divided  into  Physiological 
and  Mechanical.  A  third  class  has  been  added  by  some,  and  are  called 
Plastic  Phenomena;  by  these  are  meant  the  foetal  form-changes  pro- 
duced in  labor,  and  dependent  upon  presentation  and  position  ;  they 
are  the  deformations  which  the  presenting  part  of  the  foetus  undergoes 
in  its  transmission  through  the  birth-canal ;  they  disappear  a  few  days 
after  birth. 

PHYSIOLOGICAL  PHENOMENA.  First.  Uterine  Contractions.  As  the 
contractions  of  the  uterus  are  the  chief  power  by  which  the  foetus  and 
its  appendages  are  expelled,  their  study  is  important. 

CHARACTERISTICS  OF  UTERINE  CONTRACTIONS.  First.  They  are 
involuntary,  that  is,  independent  of  the  will ;  it  can  neither  begin  nor 
stop  them.  But  though  not  subject  to  volition,  they  may  be  affected  by 
mental  impressions.  Thus  the  presence  of  a  person  in  the  room  of  the 
parturient  who  is  disagreeable  to  her,  one  for  whom  she  has  an  antipathy, 
may  interfere  with  their  regular  action  and  power,  while  they  may  be 
immediately  arrested  by  the  arrival  of  a  stranger  who  takes  the  place 
of  the  expected  family  physician.  Profound  mental  anxiety,  grave 
apprehension  of  disaster,  and  deep  sorrow  may  lessen  the  activity  of 
uterine  contractions. 

Second.  These  contractions  are  peristaltic.  The  most  probable  view, 
derived  from  observations  of  inferior  animals,  is  that  the  peristaltic 
movements  begin  at  the  fundus  of  the  uterus. 

Third.  The  contractions  are  intermittent.  The  periods  of  action  and 
of  rest  are  different  in  different  stages  of  labor.  The  contractions  last 
about  twenty  seconds  at  the  beginning  of  labor,  and  the  intervals  are 
twenty  or  thirty  minutes  ;  toward  the  close  of  the  second  stage  of  labor 
the  former  may  last  a  minute  or  more,  while  the  latter  only  two  or  three 
minutes,  sometimes  less,  but  during  it  the  intervals  are  about  five  minutes. 
In  some  cases  the  uterus,  after  having  manifested  active  contractions  for 
a  few  hours,  pauses  in  its  work,  and  a  rest  of  some  hours  may  follow, 
after  which  its  action  is  resumed  with  new  vigor.  Such  a  pause,  there- 
fore, neither  the  condition  of  the  mother  nor  of  the  child  indicating  the 
demand  for  interference,  should  not  be  considered  pathological.  The 
ordinary  intermittence  in  the  succession  of  uterine  contractions  is  im- 
portant both  for  the  mother  and  for  the  child  ;  the  latter  is  saved  by  it 
from  a  continuous  pressure  which  would  cause  asphyxia,  and  the  former 
has  her  burden  of  suffering  divided  into  many  parts  which  can  therefore 
be  endured,  while  united  they  would  be  too  heavy  for  human  tolerance; 
and  beside,  such  continuous  and  concentrated  action  would  produce  inju- 
rious pressure  upon  her  tissues,  and  render  rupture  of  the  uterus  almost 
inevitable.  The  iutermittence  of  uterine  action  corresponds  with  that 
observed  in  other  organs,  e.  g.,  the  heart,  the  lungs,  the  intestines, 
etc.,  and  the  noblest  human  organ,  the  brain,  has  a  period  of  activity 
followed  by  one  of  repose ;  alternate  work  and  rest  seem  to  be  the  law 
of  life.  The  contractions  do  not  begin  and  end  abruptly,  each  gradu- 
ally reaches  its  maximum  and  then  declines-1- a  climbing,  and  then  a 
falling  wave;  but  in  the  latter  part  of  labor  this  characteristic  becomes 
much  less  marked. 

Fourth.  The  contractions  of  the  uterus  are  associated  with  changes 


FORCE  OF  UTERINE  CONTRACTION.  237 

iu  its  form  and  in  its  position.  During  a  contraction  the  organ  takes  a 
cylindrical  form  ;  its  transverse  diameter  is  notably  lessened,  while  both 
the  longitudinal  and  the  antero-posterior  are  slightly  increased  ;  the 
shortening  of  the  transverse  diameter  produces  some  extension  of  the 
fetus,  its  curved  form  is  lessened,  and  hence  the  slight  increase  in  the 
longitudinal  diameter  of  the  uterus.  The  broad  and  round  ligaments 
contracting  simultaneously  with  the  uterus  press  it  toward  the  pelvis ; 
the  round  ligaments  contracting  draw  the  organ  forward,  so  that  the 
fundus  rests  upon  the  abdominal  wall. 

Fifth.  The  power  of  the  contractions  is  in  proportion  to  their  fre- 
quency and  the  resistance ;  it  increases  with  the  progress  of  the  labor, 
the  duration  of  contractions  being  inversely  proportionate  to  the  inter- 
vals. The  force  and  frequency  of  uterine  contractions  are  not  in  all 
cases  in  relation  with  the  general  vigor  of  the  subject ;  these  contrac- 
tions may  be  strong  and  frequent  in  feeble,  delicate  women,  while  weak, 
and  the  intervals  long,  in  the  robust. 

Sixth.  The  character  of  the  contractions  is  related  to  the  presentation. 
Depaul  has  especially  drawn  attention  to  this  fact,  stating  that  the  con- 
tractions are  usually  more  regular  and  effective  in  presentation  of  the 
vertex.  Uniform  pressure  upon  the  lower  uterine  segment  and  the 
dilating  os  seems  necessary  in  order  to  evoke  the  regular  and  strong 
action  of  the  body  and  fundus  of  the  uterus ;  this  condition  cannot  be 
met  by  presentation  of  the  face,  of  the  breech,  or  of  the  shoulder,  and 
hence  the  contractions  present  a  manifest  irregularity.  The  physiog- 
nomy of  the  labor  will  in  most  cases  give  a  valuable  indication  as  to 
the  part  of  the  foetus  which  presents. 

It  is  not  uncommon  to  find  the  contractions  alternating  in  strength,  a 
vigorous  contraction  being  followed  by  a  feeble  contraction,  and  vice 
versa;  they  then  come  in  couples.  One  of  the  characteristics  of  uterine 
contractions  is  that  they  are  painful,  but  the  subject  of  pain  in  labor 
will  be  considered  in  another  connection. 

FORCE  OF  UTERINE  CONTRACTION.  Many  endeavors  have  been 
made  to  ascertain  the  force  exercised  in  labor.  These  have  been  by 
measuring  the  bulk  and  extent  of  the  voluntary  and  involuntary  mus- 
cles concerned  in  the  function  (Haughton} ;  by  determining  the  force 
necessary  to  rupture  the  fetal*  membranes  (Poppel  and  Duncan)  •  by 
means  of  the  tocodynamometer  (Schatz)  •  and  by  the  tocograph  (Poullet). 

Haughton's  estimate  was  577.75  pounds,  which  exceeds  that  quoted 
by  Sterne  in  Tristram  Shandy — "  470  pounds  avoirdupois  acting  upon 
the  head  of  the  child."  Poullet's  conclusion1  is  that  the  maximum 
force  of  expulsion  is  about  50  pounds.  Duncan  states  that  in  easy 
labor  a  force  scarcely  exceeding  the  weight  of  the  child  is  necessary, 
while  only  a  few  difficult  labors  require  for  their  whole  work  a  force 
exceeding  50  pounds ;  and  admitting  the  force  asserted  by  Haughton, 
he  adds  the  child  would  be  shot  out  of  the  vagina  at  the  rate  of  36  feet 
per  second.  Schatz's  estimate  is  from  17  to  55  pounds.  Ribemont  has 
repeated  the  experiments  of  Duncan,  and  has  found  that  with  the  mem- 

1  Poullet  (Archives  de  Tocologie,  1880)  refers  to  Tristram  Shandy  as  an  English  author,  and 
speaks  of  Professor  Haughton  as  "  one  of  his  corn  patriots,"  a  ludicrous  mistake,  into  which  more 
recently  Delore  and  Lutaud  (Traite  Pratique  de  1'Art  des  Accouchements.  Paris,  1883)  have  been 
led. 


238  PHYSIOLOGY  OF  LABOR. 

branes  presenting  a  surface  of  10  centimetres,  the  pressure  necessary  to- 
rupture  them  was  10  kilo.;  the  maximum,  11  kilo.  Spiegelberg 
regarded  all  estimates  as  liable  to  errors — e.  g.,  that  derived  from  the 
resistance  of  the  foetal  membranes  in  labor  to  this,  that  the  water  in 
front  of  the  presenting  head  is  not  subjected  to  the  same  pressure  as 
the  other  uterine  contents,  while  the  manometric  method  is  liable  to 
mistakes  in  measurement.  It  cannot,  therefore,  be  claimed  that  we 
know  the  entire  force,  or  that  which  is  its  chief  element,  the  contrac- 
tion of  the  uterus  as  exerted  in  labor. 

ABDOMINAL  CONTRACTIONS.  When  the  mouth  of  the  womb  is  so 
dilated  as  to  offer  little  or  no  resistance  to  the  escape  of  the  presenting 
part,  the  first  stage  of  labor  ends,  and  the  second,  or  the  utero-abdominal 
period,  begins.  The  uterine  contractions  are  now  reinforced  by  volun- 
tary contractions  of  the  muscles  of  the  abdomen.  Preparing  for  one 
of  these  efforts,  the  patient  bends  forward,  fixes  her  body  by  pressing 
the  feet  against  a  firm  object,  possibly  grasps  the  bed  or  another's  hands, 
takes  a  deep  inspiration,  pushing  the  diaphragm  down,  and  the  glottis 
is  closed  ;  the  abdominal  muscles  are  now  firmly  contracted,  thus  lessen- 
ing the  size  of  the  cavity  ;  the  pressure  from  this  contraction  is  exerted 
uniformly  upon  the  contents ;  it  is  resisted  above  by  the  depressed  dia- 
phragm, and  behind  by  the  immovable  spine;  it  acts  uniformly  upon 
the  uterus,  forcing  it  downward,  and. is  transmitted  to  its  contents. 
This  force  not  only  assists  that  of  the  uterus,  but  also  acts  as  a  counter- 
force  to  uterine  contractions,  which,  when  violent,  might,  were  it 
absent,  cause  rupture  of  the  vagina  at  its  uterine  attachment. 

While,  during  the  greater  part  of  the  second  stage  of  labor,  the 
action  of  the  abdominal  muscles  is  voluntary,  it  generally  happens  that 
toward  its  close,  just  when  the  foatal  head  is  about  to  be  expelled  from 
the  vulva,  the  patient  cannot  refrain  effort,  and  the  hitherto  voluntary 
action  becomes  purely  reflex. 

THE  THIRD  STAGE.  In  ten  to  twenty  or  thirty  minutes  after  the 
birth  of  the  child  uterine  retraction,  which  detaches,  and  then  uterine 
contractions,  which  expel  the  placenta  into  the  vagina  occur ;  they  may 
be  assisted  by  voluntary  contraction.  So,  too,  these  uterine  and  abdom- 
inal contractions,  assisted  in  some  slight  degree  by  the  elasticity  and 
contractions  of  the  vagina,  may  thrust  the  placenta  without.  Thi& 
topic  will  be  considered  more  fully  hereafter. 

PAIN.  Labor  begins,  continues,  and  ends  with  pain:  "childbirth 
is  the  only  necessarily  and  invariably  painful  function  of  the  species." 
While  in  very  rare  cases  delivery  is  without  suffering,  yet  these  are 
exceptional,  for  now,  as  of  old,  the  law1  is,  "in  sorrow  thou  shalt 
bring  forth  children."  But  pain  is  relative ;  there  is  no  measure  of 
this  phenomenon  of  vital  sense  which  can  be  universally  applied.  One 
patient  will  be  in  restless  agony  in  childbirth,  vexing  the  air  with  her 
outcries,  while  another  lies  comparatively  quiet  and  suffers  in  silence, 
because  sensation,  power  of  endurance,  and  force  of  will  so  greatly 
differ.  Nevertheless,  pain  is  not  so  great  in  the  parous  as  in  the  prim- 
ipara ;  yet  how  often  the  former  will  declare  that  they  suffer  more  in 

1  Dr.  Richert  has  said :    Pain  is  an  intellectuaT  function  so  much  more  perfect  as  the  intelli- 
gence is  more  developed. 


THE  SEAT  OF  PAIN.  239 

the  present  than  in  a  previous  labor,  simply  because  of  that  beneficent 
law  of  the  economy  which  leads  human  beings  to  forget  painful  sensa- 
tions. The  occurrence  of  pains  during  uterine  action  in  labor  is  so 
constant  that  the  name  is  generally,  and  in  almost  all  languages,  used 
as  a  synonym  for  uterine  contractions.  But  the  duration  of  a  contrac- 
tion and  of  a  pain  is  not  the  same ;  while  the  former  causes  the  latter, 
the  contraction  can  be  readily  recognized  by  the  obstetrician  with  his 
hand  upon  the  patient's  abdomen,  or  with  his  finger  at  the  os  uteri,  be- 
fore she  complains  of  any  suffering,  and  he  likewise  knows  by  the  same 
means  that  it  continues  after  all  complaint  has  ceased  ;  pain  comes  after 
contraction  begins,  and  goes  before  it  ends. 

CHARACTER  OF  THE  PAINS.  In  the  beginning  of  labor  these  are 
felt  as  a  disagreeable  pressure  downward  in  the  pelvis,  later  they  are 
felt  in  the  lumbar  and  sacral  region,  radiating  thence  to  the  pubes,  so 
that  the  patient  is  girdled  with  pain.  At  first  they  do  not  by  their 
frequency  or  their  severity  hinder  a  patient's  being  engaged  in  such 
occupations  as  reading,  sewing,  conversing,  etc.,  only  when  one  occurs 
she  pauses  for  a  minute  or  two,  a  slight  change  of  expression  is  noticed, 
a  mere  cloud  passes  over  her  face,  she  bends  her  body  forward  during 
the  brief  suffering  and  then  resumes  her  conversation,  reading,  or  work. 
The  bending  forward  is  instinctive,  and  is  said  to  be  an  effort  to  with- 
draw the  ovum  from  pressing  directly  upon  the  lower  segment  of  the 
uterus ;  but  it  is  probable  that  the  movement  is  made  in  response  to 
the  anterior  and  downward  positional  change  of  the  uterus,  caused  by 
the  contraction  of  the  broad  and  round  ligaments,  and  to  lessen  the  pres- 
sure upon  the  abdominal  wall,  just  as  more  common  abdominal  pain 
leads  to  a  similar  movement. 

During  the  first  stage  of  labor  the  pains  are  spoken  of  by  the  sufferer  as 
"  cutting,"  "  grinding,"  etc.,  but  by  the  obstetrician  as  dilating,  or  pre- 
paratory. As  the  frequency  and  intensity  of  the  uterine  contractions 
increase  so  are  the  pains  more  severe ;  the  patient  may  become  rest- 
less, irritable,  despondent,  and  discouraged,  asserting  that  she  suffers 
in  vain,  "  the  pains  do  no  good,"  "  the  child  will  never  be  born/'  and 
she  knows  she  will  die.  After  a  time,  when  the  os  has  become  fully 
dilated,  and  the  birth-canal  is  thus  prepared  for  the  descent  of  the  child, 
expulsive,  or  "  bearing-down,"  pains  occur.  The  transition  is  not  sudden 
but  gradual,  the  call  for  voluntary  effort  is  at  first  indistinct,  and  partly 
from  this,  and  partly  because  the  patient  fears  lest  such  effort  may  add 
to  her  suffering,  the  response  begins  in  a  hesitating,  tentative  way,  and 
then  gradually  becomes  equal  to  the  demand.  Hitherto  the  patient  has 
been  without  power  to  assist  the  progress  of  labor — she  has  had  only  to 
endure,  to  suffer — but  with  the  establishment  of  the  second  stage  active 
duty  devolves  on  her,  and  she  usually  becomes  hopeful  and  resolute; 
no  longer  moaning  and  groaning,  her  lips  are  closed  while  voluntary 
abdominal  pressure  combines  with  uterine  contraction  to  drive  the  foetus 
down  the  birth-canal,  abrupt  expiration  occurs  at  the  close  of  a  pain, 
with  a  sudden  and  guttural  outcry.  The  practitioner  soon  learns  to 
know  by  a  patient's  cry  whether  she  is  in  the  first  or  second  stage  of 
labor. 

THE  SEAT  OF  PAIN.     Madame  Boivin,  who  knew  from  personal 


240  PHYSIOLOGY  OF  LABOR. 

experience  the  suffering  of  childbirth,  thought  the  pain  was  almost  en- 
tirely the  result  of  stretching  the  os  uteri.  Depaul  said  that  in  the  first 
stage  of  labor  it  was  in  the  lateral  and  lower  parts  of  the  uterus,  but 
afterward  it  arose  from  pressure  of  the  foetus  upon  the  organs  and 
tissues  of  the  pelvic  cavity.  According  to  Spiegel  berg,  form-changes  in 
the  uterus  and  of  separate  muscular  fasciculi  in  its  walls,  permitting  pres- 
sure on  nerves,  are  causes  of 'suffering.  The  pressure  upon  the  tissues 
surrounding  the  vulval  orifice  made  during  its  dilatation  also  causes 
severe  pain. 

DILATATION  OF  THE  Os  UTERI.  At  the  beginning  of  labor  the 
cervix  has  disappeared,  only  a  slightly  projecting  border — more  pro- 
nounced in  multipart — marking  the  boundary  of  the  os  uteri.  This  is 
the  first  barrier  to  the  escape  of  the  foetus,  and  dilatation  of  the  os,  there- 
fore, is  the  first  part  of  labor.  This  dilatation  is  at  once  active  and 
passive ;  the  muscular  fibres  of  the  body  and  the  fundus  overcome  the 
resistance  of  the  circular  fibres  of  the  os,  and  the  pressure  of  the  ovum 
upon  the  os,  made  by  the  projecting  membranes  filled  with  amnial  liquor 
— the  bag  of  waters — mechanically  dilates  it.  Further,  this  uniform 
pressure  of  the  ovum  upon  the  lower  segment  and  mouth  of  the  womb 
evokes  regular  and  stronger  contractions  from  the  body  and  fundus ; 
and  thus,  in  addition  to  its  mechanical  dilatation,  assists  labor.  When 
the  uterus  contracts  the  cavity  lessens,  its  walls  tend  to  approach  a  com- 
mon centre ;  but  the  ovum  resists,  and  the  resultant  of  the  forces 
developed  by  the  contracting  muscular  fasciculi  is  transmitted  in  the 
direction  of  least  resistance,  that  is,  to  the  os  uteri,  from  which  a  part  of 
the  ovum,  this  part  increasing  with  the  progress  of  the  labor,  protrudes. 
As  the  os  uteri  expands  the  cavity  lessens ;  and  the  former,  by  the  con- 
traction of  the  longitudinal  fibres  of  the  uterus  tends  to  ascend,  drawn 
up  over  the  ovum  or  the  presenting  part.  At  the  beginning  of  a  con- 
traction the  rim  of  the  os  uteri  becomes  thicker,  irregular,  as  if  " puck- 
ered/' and  the  opening  smaller,  but  with  the  progress  of  the  uterine 
effort  the  border  becomes  thin,  irregular,  uniform  in  thickness,  and  the 
opening  expands ;  with  the  advance  of  the  labor  the  lessening  of  the  os 
at  the  beginning  of  a  contraction  is  not  observed,  but  dilatation  alone. 

In  primi  parse  the  border  of  the  os  uteri  is  at  the  beginning  of  labor 
very  thin,  scarcely  thicker  than  parchment,  is  closely  applied  to  the  foetal 
head,  and  during  a  uterine  contraction  seems  like  a  tense  cord  ;  but  with 
the  progress  of  the  labor  it  becomes  thicker  and  swelled,  especially  at 
the  anterior  part,  and  it  is  more  dilatable ;  it  never,  however,  becomes 
so  thin  as  it  was  at  first. 

The  dilatation  rapidly  increases  with  the  progress  of  the  labor, 
nearly  as  much  time  being  needed  for  the  os  to  be  stretched  to  the 
size  of  a  silver  dollar,  as  from  this  to  reach  complete  expansion.  The 
process  is  more  rapid  in  the  parous  than  in  the  primipara.  At  the 
beginning  of  labor  the  os  is  usually  posterior  and  to  the  left ;  but  with 
its  progress  it  comes  nearer  the  centre ;  its  form  is  at  first  circular,  then 
oval,  the  large  end  of  the  oval  being  to  the  left  and  somewhat  behind. 
The  posterior  lip  generally  yields  before  the  anterior,  the  uterine  orifice 
being  nearer  to  the  sacrum  than  it  is  to  the  pubes ;  if  the  labor  be  pro- 
longed, the  anterior  lip  in  most  cases  becomes  cedematous. 


THE  BAG  OF  W A  TEES. 


241 


THE  BAG  OF  WATERS.  The  ovum  being  equally  pressed  at  all  points 
except  at  the  os  uteri  projects  there,  and  that  portion  of  the  membranes 
containing  amniotic  liquor  thus  protruding,  "  making  a  hernia  through 
the  more  or  less  dilated  os,"  is  the  bag  of  waters.  The  size  and  form 
of  this  protrusion  are  usually  dependent  upon  the  degree  of  dilatation 
and  upon  the  presentation.  When  the  os  is  but  slightly  dilated  the 
bag  of  waters  is  small ;  so,  too,  in  vertex  presentation  it  is  at  first 
little,  and  has  the  form  of  a  watch-crystal,  but  as  the  dilatation  ap- 

FlG.  106. 


THE  BAG  OF  WATERS. 

proaches  completion  it  is  large,  and  is  hemispherical.  The  bag  is  great 
in  presentation  of  the  face,  of  the  breech,  or  of  the  shoulder,  because 
no  one  of  these  parts  can  be  adapted  to  the  cervico-uterine  canal,  but 
permits  the  amnial  liquor  to  pass  freely  by  it ;  the  great  size  of  the  bag 
of  waters  rather  than  the  form  is  an  indication  of  an  unfavorable  presen- 
tation, especially  when  this  is  observed  during  the  dilatation  of  the  os 
uteri,  and  the  presenting  part  of  the  foetus  does  not  readily  descend.  A 
double  bag  of  waters  is  observed  in  some  cases  of  twin  pregnancy. 

16 


242  PHYSIOLOGY  OF  LABOR. 

The  pouch  is  smooth  and  tense  during  uterine  contractions,  relaxed 
and  yielding  in  the  intervals.  Tarnier's  experiments  have  proved  that 
the  membranes  are  permeable  by  fluids,  so  that  a  moist  condition  of  the 
vagina  is  not  a  proof  of  rupture  of  the  sac.  The  bag  of  waters  acts  as 
a  hydrostatic  dilator  of  the  os  uteri,  the  best  and  the  least  painful  one ; 
and  therefore  care  must  be  taken  to  guard  against  its  premature  rupture. 
In  some  cases  rupture  takes  place  before  labor,  or  as  the  first  indication 
that  labor  has  begun,  the  patient  being  awakened  from  her  sleep  in  the 
night  by  a  gush  of  water;  this  accident  is  more  frequent  in  primi- 
gravidse  than  in  multigravidae,  because  in  the  former  the  uterine  walls 
are  more  resisting,  and  yield  less  readily  to  distention.  When  the  waters 
are  evacuated  before  or  at  the  beginning  of  uterine  contractions  the 
labor  is  called  a  dry  labor,  and  the  first  stage  is  generally  quite  tedious. 

A  collection  of  fluid  between  the  ovum  and  the  uterus  or  between 
the  amnion  and  the  chorion  may  take  place,  and  its  discharge  simulate 
that  of  the  amuial  liquor ;  when  this  occurs  the  flow  is  known  as  the 
'' false  waters,"1  and  probably  most  of  the  cases  in  which  it  is  thought 
that  the  ovum  was  ruptured  sometime  before  labor  are  thus  explained. 
This  last  statement,  however,  does  not  apply  to  all,  for  there  are  authen- 
tic cases  in  which  the  rupture  took  place  some  weeks  before  labor. 
Poullet,  quoted  by  Tarnier,  gives  one  instance  of  rupture  six  weeks, 
another  nine  weeks  before  labor,  and  then  a  living  foatus  being  born  in 
each  case.  Matthews  Duncan  mentions  an  instance  in  which  the  preg- 
nancy continued  for  forty-five  days  after  the  first  discharge  of  amnial 
fluid ;  he  also  states  that  a  medical  friend,  mistaking  pregnancy  for  an 
ovarian  dropsy,  performed  paraceutesis,  drawing  off  a  large  quantity  of 
amnial  liquor,  when  he  desisted  because  feeling  the  fretus  strike  against 
the  can u la,  and  yet  the  pregnancy  did  not  end  for  a  month.  If  one  is 
in  doubt  whether  the  fluid  discharged  in  a  given  case  be  liquor  amnii, 
and  enough  of  it  can  be  collected  for  examination,  the  presence  or  absence 
of  sebaceous  matter  promptly  settles  the  question. 

In  rare  instances,  less  rare  in  premature  than  in  mature  labor,  the 
ovum  is  expelled  entire.  Under  these  circumstances  the  membranes 
were  known  as  a  child's  caul,  which  once  was  in  demand  by  sailors  as 
an  amulet  that  would  keep  its  possessor  from  drowning.  Formerly, 
when  the  child  was  born  with  a  flap  of  membranes  covering  the  head, 
the  fact  was  regarded  as  a  favorably  augury.2 

The  bag  of  waters  is  usually  spontaneously  ruptured  about  the  time 
the  os  uteri  is  fully  dilated ;  in  some  cases,  however,  it  may  protrude 
from  the  vulval  orifice  before  being  torn.  As  a  rule,  the  rent  is  at  the 
most  dependent  part  of  the  pouch,  and  the  water  escapes  suddenly  and 
with  noise ;  but  it  may  be  above  in  the  cervico-uterine  canal,  and  the 
flow  is  gradual  and  silent,  while  the  part  of  the  membranes  in  front 
of  the  child's  head  being  entire  still  forms  a  pouch.  The  quantity  of 
fluid  discharged  depends  upon  the  presentation  ;  thus  if  the  vertex  pre- 
sent, the  head  makes  a  ball-valve  which,  when  pressed  down  during  a 

i  These  discharges  are  generally  caused  by  catarrhal  endoinetritis. 

*  Caul  on  the  Head.  In  Dean  Swift's  Polite  Conversations  one  of  the  female  characters  remarks  to 
a  gentleman,  "  I  believe  you  were  born  with  a  caul  on  your  head,  you  are  such  a  favorite  with  the 
ladies." 


DILATATION  OF  THE  VULVA.  943 

uterine  contraction  entirely  arrests  the  flow,  and  permits  only  a  slight 
discharge  in  the  interval ;  no  other  part  of  the  foetal  ovoid  which  may 
present  can  so  well  fill  the  cervico-uterine  canal,  but  by  its  irregular 
form  readily  permits  the  escape  of  the  amnial  liquor.  It  is  often  ob- 
served in  vertex  presentations  that  when  the  head  has  descended  so  that 
partial  deflection — a  movement  which  some  authors  describe  in  the 
mechanism  of  labor  as  levelling — can  take  place,  there  is  an  increased 
flow  of  liquor  amnii,  because  the  neck  does  not  completely  fill  the  canal. 

It  is  very  important  for  the  obstetrician  to  know  whether  the  mem- 
branes are  ruptured.  Generally  there  is  no  difficulty  in  deciding  this 
question,  but  cases  occasionally  occur  in  which  it  is  very  great,  and 
some  deplorable  mistakes  have  been  made ;  thus  the  forceps  has  been 
applied  to  the  foetal  head  enclosed  in  the  membranes,  the  distended 
bladder  has  been  thought  the  bag  of  waters  and  incised,  causing  a 
vesico- vaginal  fistula,  and  the  foetal  scalp  similarly  mistaken  and  treated 
in  like  manner,  the  incision  being  the  starting-point  of  a  fatal  erysipelas. 
A  knowledge  of  the  fact  that  such  errors  have  been  committed,  and 
hence  the  possibility  of  their  repetition,  may  prove  a  warning  against 
the  hurried  and  imperfect  examination  in  which  they  originate.  In 
doubtful  cases  the  obstetrician  should  examine  during  a  pain — of  course, 
taking  care  to  avoid  rupture  of  the  pouch  if  it  be  present — for,  however 
closely  the  membranes  may  be  applied  to  the  head  when  the  uterus  is 
at  rest,  there  will  then  always  be  found  some  fluid  interposed  which 
causes  their  projection.  In  the  interval  between  pains  the  membranes 
are  flaccid,  and  the  finger  can  press  them  in  wrinkles  or  folds  which 
give  a  different  sensation  from  that  caused  by  directly  touching  the 
foetal  scalp.  Finally,  Charpentier  advises  carrying  the  finger  as  far  as 
possible  between  the  head  of  the  foetus  and  the  cervix,  thus  opening  a 
way  by  which,  if  the  membranes  have  been  ruptured,  the  liquor  amuii 
will  flow  down  into  the  palm  of  the  hand. 

MUCO-SANGUINEOUS  DISCHARGE.  A  greater  discharge  from  the 
external  genital  organs  and  from  the  vagina  is  observed  toward  the 
close  of  pregnancy,  but  with  the  beginning  of  labor  an  increased  secre- 
tion from  the  glands  of  the  cervix  occurs.  The  character  of  the  latter, 
as  well  as  the  significance  of  the  blood  often  found  mixed  with  it,  has 
already  been  stated  ;  the  discharge  of  any  considerable  amount  of  blood 
with  it  would  indicate  most  probably  either  a  serious  rent  of  the  cervix 
or  a  partial  detachment  of  the  placenta. 

DILATATION  OF  THE  VAGINA.  The  upper  part  of  the  vagina  is 
dilated  by  the  descent  of  the  lower  portion  of  the  uterus  containing  the 
foetal  head,  and  by  the  stretching  of  the  margin  of  the  os  uteri,  so  that 
there  is  formed  a  complete  utero-vaginal  canal  ample  for  the  passage  of 
the  head ;  no  resistance  is  presented  until  the  inferior  boundary  of  the 
vagina  is  reached;  in  primiparge  the  hymen  is  an  obstacle  which  is 
removed  by  a  series  of  rents.  Budin  has  shown  that  the  vaginal 
orifice  may  present  a  resistance  lasting  some  hours,  which  has  been 
commonly  attributed  to  the  perineum ;  in  one  case  in  which  there  was 
delay  from  this  cause,  he  incised  the  vaginal  orifice,  and  the  labor 
ended  rapidly  without  injury  to  the  perineum  or  to  the  vulva. 

DILATATION  OF  THE  VULVA.     The  head  now  enters  the  vulval 


244 


PHYSIOLOGY  OF  LABOR. 


canal,  the  perineum  is  behind,  the  labia  at  its  sides,  and  the  uterine 
contractions,  whose  force  is  increased  with  the  partial  emptying  of  the 
uterus,  and  the  abdominal,  which  are  stronger  from  reflex  irritation 
caused  by  the  head  pressing  on  the  perineum,  drive  the  presenting  part 
like  a  wedge,  widely  separating  the  vulval  walls.  The  perineum  is 
greatly  elongated  and  so  thinned  that  the  bones  of  the  fetal  head  may 
be  felt  through  it;  it  is  converted  into  a  glitter,  externally  from  side  to 
side,  and  from  before  .backward  ;  its  elastic  tissue  and  muscles  direct 
the  head  upward.  Each  pain  pushes  the  head  further,  but  it  recedes  in 


HEAD  AT  THE  VULVAL  OPENING.' 

the  interval  between  pains — the  parts  are  stretched  and  then  relaxed  ; 
the  anus  is  widely  opened,  and  the  anterior  wall  of  the  rectum  exposed, 
making  a  part  of  the  external  covering  of  the  foetal  head  ;  the  labia  are 
separated  by  the  head,  more  and  more  of  this  emerging  at  each  con- 
traction, which  seems  as  if  it  were  to  be  the  last  needed  for  its  expul- 
sion, until  finally  the  parietal  protuberances  escape  the  rim  of  the  vulva, 
and  there  is  no  more  recession,  for  the  bearing-down  effort  seems  almost 
continuous,  scarcely  a  pause  for  breath,  until  in  a  conquering  agony  and 
with  the  most  intense  suffering  the  head  is  born.  A  brief  pause  fol- 
lows, and  returning  pains  expel  the  body  of  the  child;  immediately 
following  it  the  remaining  portion  of  the  liquor  amuii,  frequently  some 
blood  from  a  partially  detached  placenta  with  it,  is  discharged. 

DETACHMENT  AND  DISCHARGE  OF  THE  PLACENTA.     The  separa- 

1  "In  this  figure,  copied  from  Smellie,  the  child's  head,  a,  is  seen  separating  the  labia;  the 
extension,  thinning,  and  protrusion  of  the  perineum,  b,  caused  by  the  head's  descent,  and  called 
by  some  the  perineal  tumor,  are  also  well  portrayed  ;  d  marks  the  point  of  the  coccyx  ;  c  the  anus 
dilated,  so  that  the  inner  membrane  of  the  rectum  is  to  some  extent  exposed  to  the  contact  of  the 
hand,  when  applied  for  the  protection  of  the  structures.  This  exposure  is  not  injurious  ;  no  harm 
arises  from  it :  and  sometimes  it  is  even  greater  than  is  represented  here."  Ramsbotham. 


DETACHMENT  AND  DISCHARGE  OF  THE  PLACENTA.         245 

tion  of  the  placenta  from  the  uterine  wall  has  been  differently  explained, 
and  probably  does  not  always  occur  in  the  same  manner,  varying,  too, 
according  to  the  part  of  the  uterus  to  which  it  is  attached.  If  the  pla- 
centa has  its  site  at  the  fund  us  of  the  uterus,  detachment  may  begin  at 
the  centre,  and  effusion  of  blood  occur  which  by  pressure  continues  the 
separation  to  the  periphery  of  the  organ.  In  one  of  Winter's  frozen 
sections  this  mode  of  separation  is  shown,  and  it  is  that  which  is  known 
as  Schultze's.  Necessarily  there  is  inversion  of  the  placenta  in  these 
cases,  and  the  organ  presents  at  the  os  uteri  with  its  foetal  surface. 

Ahlfeld1  describes  as  the  most  frequent  mode  of  separation,  occur- 
ring in  about  75  per  cent,  of  cases,  the  placenta  being  situated  at  the 
anterior  or  posterior  wall  of  the  uterus,  the  central  portion  of  the  pla- 
centa is  lifted  off,  and  the  retro-placental  hematoma  presses  the  under 
half  of  the  placenta  into  the  contraction -ring.  The  border  of  the  pla- 
centa, perhaps  also  the  adjacent  portion  of  membranes,  enters  deeper, 
then  the  central  part,  finally  the  upper  part  of  the  placenta  descends, 
until  the  inversion  and  the  pressing  out  from  the  uterine  cavity  is 
completed. 

Pinard  and  Varnier2  state  that  the  forces  which  cause  placental  de- 
tachment are  the  elasticity,  the  retractility,  and  the  contractility  of  the 
muscular  tissue  of  the  uterus.  "During  and  immediately  after  the  ex- 
pulsion of  the  foetus  the  uterus  tends  to  recover  its  form,  that  is  to 
say,  each  part  of  its  wall  tends  to  approach  the  centre  of  the  cavity. 
That  portion  of  the  wall  which  corresponds  to  the  insertion  of  the  pla- 
centa is  more  remote  from  this  centre  because  of  the  presence  of  the 
placenta  and  of  its  less  elastic  force,  retractile  and  contractile,  for  its 
wall  is  thinner.  These  muscular  elements  accumulated  around  the  pla- 
centa exercise  their  action  upon  the  thinned  part  and  lessen  its  surface. 
It  is  easily  understood  that  this  action  would  be  in  direct  proportion  to 
the  acting  muscular  mass,  that  is  to  say,  the  detachment  will  be  made 
more  quickly  the  thicker  the  uterine  wall."  The  membranes  remain 
adherent,  except  in  the  lower  uterine  segment ;  there  they  have  been 
detached  during  labor.  The  weight  of  the  placenta  and  uterine  action 
determine  the  separation  of  the  still  adherent  membranes.  Pinard  and 
Varnier  say  that  "  the  plate  of  Schroder  and  of  Schatz  and  their  own 
conclusively  prove  that  the  placenta  may  be  in  the  lower  segment  of  the 
uterus  and  even  in  the  vagina,  suspended,  as  it  were,  by  the  membranes 
still  retained  and  adherent  in  the  uterine  cavity."  They  add  the  im- 
portant rule  derived  from  this  fact:  Never  begin  or  continue  tractions 
upon  the  cord  during  uterine  contraction,  even  though  the  placenta  is 
already  in  the  vagina  or  at  the  vulva.  The  consequence  of  such  un- 
timely traction  will  be  the  probable  retention  of  fragments  of  the  mem- 
branes in  the  uterus. 

Berry  Hart3  maintains  that  the  separation  of  the  placenta  is  accom- 
plished, not  by  contraction,  but  by  expansion  of  the  area  of  uterine 
attachment.  "However  much  the  area  diminishes  the  placenta  cannot 
separate,  because  the  disproportion  necessary  cannot  take  place.  When 

1  Lehrbuch  der  Geburtshiilfe. 

2  Precis  d'Obstetrique,  by  Ribemont-Dessaignes  and  Lepage. 

3  Selected  Papers  in  Gynecology  and  Obstetrics.  1893. 


246  PHYSIOLOGY  OF  LABOR. 

the  uterus  contracts  to  the  amount  it  does  after  the  child  is  born  the 
placenta  fills  the  uterine  cavity,  and  any  further  diminution  in  uterine 
bulk  never  leads  to  a  disproportion  between  placenta  and  the  area  of 
the  uterine  muscle  to  which  it  is  attached,  but  the  two  are  always  equiv- 
alent. After  the  pain  has  died  off  the  uterus  relaxes,  and,  as  a  matter 
of  fact,  has  an  increase  in  area  in  its  anterior  and  posterior  surfaces. 
Now  comes  in  a  different  phase  in  the  behavior  of  the  placenta.  The 
foetal  blood  has  been  aspirated  from  it;  the  iutervillous  spaces  are 
empty,  and,  therefore,  during  the  increase  in  the  internal  uterine  area, 
we  have  cut  off  the  two  factors  in  bringing  about  the  equivalent  ex- 
pansion in  area  during  the  relaxation  following  the  pains  of  the  first 
and  second  stages,  i.  e.,  we  get  the  placenta  smaller  in  area  at  the  place 
of  separation  than  the  placental  site.  This  repeated  disproportion  in 
area,  i.  e.,  slight  excess  of  area  of  the  placental  site  over  the  placenta 
itself,  tear  the  partitions  in  the  spongy  layer,  i.  e.,  separates  the 
placenta." 

After  the  placenta  is  detached  contractions  of  the  body  of  the  uterus 
drive  it  into  the  lower  segment,  whence  the  same  force  compels  its  pas- 
sage through  the  os  uteri.  In  this  passage  the  foatal  face  presented, 
according  to  the  observations  of  Pinard  and  Varnier,  789  times  in  1000 
cases,  the  border  of  the  placenta  166  times,  and  the  uterine  surface  45 
times. 

FALSE  PAINS.  It  sometimes  happens  that  women  during  the  latter 
part  of  pregnancy  have  what  are  called  "  false  labor  pains."  These 
have  been  attributed  to  rheumatism  of  the  womb,  to  local  uterine  con- 
tractions, to  contractions  of  the  abdominal  muscles,  and  to  intestinal 
irritation.  The  last  is  probably  the  most  frequent  cause.  False  are 
distinguished  from  true  pains  by  their  not  having  been  preceded  by  the 
premonitory  symptoms  of  labor;  by  their  situation,  for  they  are  not 
felt  in  the  back,  and  from  it  extending  in  front,  but  in  the  abdomtn, 
sometimes  in  one,  and  again  in  another  part  of  it;  by  their  being 
irregular  in  recurrence,  not  increasing  in  severity,  and  not  causing  any 
change  in  the  os  uteri.  On  the  other  hand,  labor  has  begun  when  gen- 
eral contractions  of  the  womb  and  progressive  dilatation  of  its  mouth 
occur. 

THE  EFFECTS  OF  LABOR  UPON  THE  MOTHER.  Parturition  has  an 
influence  upon  various  functions  of  the  maternal  organism.  The  desire 
for  food  is  lessened  or  lost;  it  is  not  unusual  for  nausea  and  vomiting 
to  occur,  especially  toward  the  end  of  the  first  stage,  and  these  are 
thought  to  facilitate  dilatation  of  the  mouth  of  the  womb,  a  common 
belief  being  that  sick  labors  are  easy  labors.  But  while  this  gastric  dis- 
turbance is  regarded  as  a  good  omen  in  the  first  stage,  a  very  different 
character  belongs  to  the  vomiting  which  may  occur  in  the  second  stage, 
with  cessation  of  labor  activity,  and  with  exhaustion  of  the  patient; 
the  symptom  is  then  dangerous,  and  immediate  delivery  is  required. 
The  pulse  increases  in  frequency  during  a  uterine  contraction,  lessening 
at  its  close;  as  this  contraction  drives  much  of  the  blood  from  the  uterus 
into  the  general  circulation,  arterial  tension  is  greater.  Increased  arterial 
tension  and  nervous  irritation  cause  a  greater  secretion  of  urine ;  at  first 
this  fluid  has  a  less  specific  gravity  than  normal,  but  afterward  the 


DURATION  OF  LABOR.  247 

quantity  of  salts  is  greater.  A  slight  shivering  is  observed  in  some 
patients  at  the  beginning  of  each  contraction.  The  respirations,  less 
frequent  during  a  pain,  are  more  frequent  during  an  interval ;  the  tem- 
perature of  the  body,  as  well  as  that  of  the  uterus,  is  slightly  increased. 

In  the  second  stage  the  face  is  usually  red  and  swelled,  and  it,  and 
also  the  body  and  limbs,  are  bathed  with  perspiration.  Patients  in  the 
absence  of  pains  frequently  are  drowsy  and  disposed  to  sleep,  this  con- 
dition resulting  in  part  from  fatigue  and  in  part  from  cerebral  conges- 
tion. In  labor  some  women  are  irritable,  restless,  and  lose  all  self-con- 
trol; but  the  majority  pass  through  the  terrible  ordeal  with  patience 
and  resignation,  if  not  always  with  hope.  A  woman  loses  in  labor  one- 
ninth  of  her  weight ;  the  amount  of  loss  is  somewhat  less  in  the  primi- 
parous  than  in  the  parous ;  the  loss  is  of  course  chiefly  due  to  the 
removal  of  the  ovum,  but  the  increased  quantity  of  urine  secreted,  the 
perspiration,  and  the  blood  discharged  with  the  placenta,  contribute  to  it. 

THE  EFFECTS  OF  LABOR  UPON  THE  FOZTUS.  Uterine  contractions 
cause  temporary  modifications  in  the  foetal  circulation  ;*  at  the  begin- 
ning of  a  contraction  there  is  a  slight  acceleration  in  the  pulsations  of 
the  foetal  heart,  then  these  become  slower  when  the  contraction  is  strong ; 
and,  finally,  when  the  tension  of  the  uterus  lessens,  the  double  pulsa- 
tions increase  in  order  to  resume  their  ordinary  rhythm.  The  slowing 
of  the  foetal  heart  during  a  contraction  of  the  uterus  is  probably  due  to 
slight  asphyxia  from  partial  interruption  of  the  placental  circulation ; 
it  has  also  been  attributed  to  greater  intra-cardiac  pressure,  and  to  com- 
pression of  the  head.  Pressure  upon  the  foetus  may  cause  evacuation 
of  the  bladder  or  of  the  rectum;  discharge  of  the  meconium  is  com- 
mon in  presentation  of  the  breech.  If  the  placental  circulation  be  inter- 
rupted, and  hence  the  foetus  threatened  with  asphyxia,  instinctive  efforts 
to  respire  by  the  lungs  are  made.  When  the  child  is  still  unborn,  if 
air  enter  its  respiratory  organs,  it  may  cry,  and  to  this  cry  the  name  of 
vagitus  intra-uterinus  has  been  given.  The  fact  has  been  attested  by 
reputable  observers,  but  of  course  is  exceedingly  rare. 

DURATION  OF  LABOR.  This  varies  with  race,  climate,  place  and  man- 
ner of  living,  heredity,  age,  organization,  physical  conformation,  and 
whether  first  or  subsequent  labor,  and  with  the  sex,  presentation,  and 
position  of  the  child.  Labor  is  said  to  be  shorter  in  warm  than  in  cold 
climates,  in  savage  than  in  civilized  races,  in  women  in  the  country, 
accustomed  to  plain  food,  out-door  exercise,  and  regular  hours  of  rest, 
than  in  those  leading  opposite  lives  in  the  city.  In  primiparse  labor  is 
longer  than  in  multipart;  it  is  longer  also  in  face  or  breech  than  in 
vertex  presentations,  in  occipito-posterior  than  in  occipito  anterior  posi- 
tions, with  male  than  with  female  children. 

In  primipara?  the  usual  period  of  labor  is,  according  to  Depaul,  fifteen 
to  twenty  hours,  but,  according  to  Tarnier,  twelve  to  fifteen  hours;  in 
multipart  six  to  eight  hours.  Hecker  and  Ahlfeld  state  that  the  aver- 
age duration  of  labor  in  primiparse,  thirty  years  old  and  more,  is  twenty- 
one  to  twenty-seven  hours ;  Dieterlen's  study  of  labor  in  2369  primi- 
par&3,  the  delivery  being  natural,  shows  that  up  to  thirty-five  years  the 

1  Depaul. 


248  PHYSIOLOGY  OF  LABOR. 

duration  varies  but  little,  aud  is  fifteen  to  sixteen  hours,  but  that  from 
thirty-five  it  rapidly  increases,  so  that  in  priraiparee  above  forty-oue 
years  it  is  thirty-three  hours.  The  average  of  all  labors  is,  according 
to  Naegele,  twelve  to  fifteen  hours.  The  second  stage  of  labor  is  gener- 
ally one-third  that  of  the  first.  The  majority  of  labors  begin  between 
9  and  12  P.M.  aud  end  between  9  P.M.  and  9  A.M. 

PLASTIC  PHENOMENA  OF  LABOR  IN  VERTEX  PRESENTATIONS.  By 
these  phenomena  are  meant,  not  only,  as  previously  stated,  the  changes 
in  the  form  of  the  cranium  caused  by  labor,  but  also  the  production  of 
the  caput  succedaneum.  The  head  delivered  in  an  occipito-anterior  posi- 
tion presents  a  cylindrical  form  ;  the  occipito-frontal  and  occipito-mental 
diameters  are  lessened,  but  the  maximum  diameter  is  increased ;  the 
suboccipito-bregmatic,  the  bitemporal,  aud  the  biparietal  diameters  are 
lessened.  According  to  Dohrn,1  there  is  an  asymmetry  of  the  two 
lateral  halves  of  the  cranium,  marked  by  the  prominence  of  one  of  the 
parietal  bones,  aud  by  the  flattening  of  the  other,  which  is  sometimes 
pushed  farther  in  front,  sometimes  farther  back  than  the  one  on  the 
opposite  side,  so  that  the  parietal  protuberances  are  not  equidistant  from 
the  occipital  protuberance.  In  occipito-sacral  delivery  the  head  has  the 
appearance  of  being  drawn  out  vertically  from  below  above;  the  vertex 
makes  a  conical  projection,  so  that  the  head  lias  the  form  of  a  sugar- 
loaf.  The  forehead  and  the  anterior  part  of  the  parietal  bone  are  almost 
upon  the  same  vertical  plane ;  the  occiput  is  flattened  and  pushed  in  front. 

CAPUT  SUCCEDANEUM.  This  is  the  name  given  to  a  tumor  com- 
posed of  asero-sanguineous  infiltration  of  the  connective  tissue,  situated 
upon  the  presenting  part  of  the  foetus.  The  swelling  occurs  upon  that 
part  which  is  not  subjected  to  pressure.  "  In  the  course  of  labor,2  after 
the  evacuation  of  the  liquor  amnii,  the  child  is  during  pains  subjected 
to  strong  pressure  from  the  parturient  forces,  and  equally  strong  counter- 
pressure  from  the  resisting  maternal  passages.  Every  part  of  the  child 
is  subjected  to  these  forces,  except  that  adjacent  to  the  as  yet  uudilated 
passage  through  which  the  child  is  being  urged." 

The  caput  succedaneum  does  not  fluctuate,  pits  on  pressure,  and  is 
violet-colored.  The  longer  and  more  difficult  the  labor,  the  larger  this 
swelling.  By  some  it  has  been  improperly  termed  cephalhaematoma ; 
Bouchut  describes  it  under  the  name  of  supra-periosteal  cephalhgema- 
toma,  or  pseudo-cephalhaematoma.  Cephalhaematoma  is  an  effusion  of 
blood  between  the  periosteum  and  the  bone;  it  is  more  frequently 
found  upon  the  right  than  upon  the  left  parietal  bone,  in  some  cases 
upon  both,  in  others  upon  the  occipital,  upon  the  temporal,  or  upon  the 
frontal.  The  affection  rarely  occurs.  Bouchut3  describes  it  as  an  indo- 
lent, distinctly  circumscribed,  soft,  and  fluctuating  tumor,  and  attended 
by  no  discoloratiou  of  the  skin ;  it  may  be  as  large  as  a  pullet's  egg. 
The  severity  or  great  length  of  the  labor  has  no  influence  upon  its  pro- 
duction. There  may  be  felt  in  many  cases  a  bony  circle  at  its  base 
separating  it  from  adjacent  parts. 

In  left  occipito-auterior  position  the  caput  succedaueum  is  upon 
the  posterior  and  superior  angle  of  the  right  parietal  bone.  In  left 

1  Tarnier.  2"  Duncan.  3  Op.  cit. 


CAPUT  SUCCEDANEUM.  249 

occipito-posterior  position  it  occupies  the  superior  and  anterior  angle 
of  the  right  parietal  bone.  In  right  occipito-anterior  position  the  caput 
succedaneum  is  at  the  posterior  and  superior  augle  of  the  left  parietal ; 
and  in  right  occipito-posterior  position,  at  the  superior  and  anterior 
angle  of  the  same  boue.  If  in  consequeuce  of  slight  resistance  the 
labor  be  very  rapid,  no  caput  succedanum  may  be  formed. 

After  the  head  has  descended  to  the  pelvic  floor,  and  anterior  rota- 
tion occurred,  if  delivery  be  delayed,  a  secondary  caput  succedaueum 
will  be  formed;  but  this  will  be  always  in  the  median  line,  and  not 
limited  to  one  of  the  parietal  bones. 

While  early  rupture  of  the  membranes,  the  labor  being  protracted, 
causes  greater  size  of  the  caput  succedaueum,  yet  it  may  begin  before 
this  rupture.  In  such  exceptional  cases  Matthews  Duncan  suggests 
"  the  liquor  amnii  must  be  in  such  minute  quantity  as  to  have  no 
hydrodynamical  properties  "  But  it  seems  a  clearer  explanation  to  say 
the  event  occurs  because  of  the  minute  quantity  of  this  fluid  in  advance 
of  the  head,  for  the  statement  quoted  is  at  least  ambiguous. 

The  caput  succedaneum  is  not  found  if  the  foetus  is  dead,  and  Runge 
suggests  that  this  may  be  an  important  mark  in  doubtful  cases  as  to  the 
life  of  the  child. 

This  effusion  in  the  connective  tissue  disappears  in  a  day  or  two ; 
while  a  subperiosteal  hemorrhage,  or  true  cephalha3matoma,  will  last 
from  ten  to  sixty  days. 


CHAPTER  XI. 

THE   MECHANICAL   PHENOMENA   OF   LABOR. 

THE  mechanical  phenomena  of  labor  are  the  passive  movements 
given  the  foetus  in  its  expulsion.  These  phenomena  are  included  under 
the  general  term  mechanism  of  labor.  The  efficient  cause  of  labor  is 
the  force  of  uterine  and  of  abdominal  contractions  ;  the  final  cause,  that 
is,  the  design,  is  birth  ;  but  the  former  in  accomplishing  this  end  must 
act  by  material  and  formal  causes.  Now,  the  material  cause  is  the  foetus 
and  the  birth-canal,  aud  the  formal  cause  includes  the  adaptations  of 
the  former  to  the  latter,  adaptations  by  which  its  transmission  is  ren- 
dered possible.  Certain  diameters  of  the  foetal  head  are  greater  than 
any  of  the  pelvic  diameters,  and  hence  if  the  former  be  brought  into 
relation  with  the  latter,  the  further  movement  of  the  foetus  is  impossi- 
ble. The  birth-canal  presents  an  axis  of  emergence  almost  perpendic- 
ular to  the  axis  of  entrance,  and  therefore  the  foetus  going  into  that 
canal  in  one  direction  must  take  another  and  very  different  direction  in 
order  to  pass  out.  The  longest  diameter  of  the  pelvic  inlet  is  an  oblique 
diameter,  while  that  of  the  outlet  is  antero-posterior ;  hence  a  diameter 
of  the  foetal  head,  which  requires  the  space  given  by  the  former  for  its 
transmission,  will,  when  it  descends  to  the  outlet,  need  to  be  placed  in 
relation  with  the  latter  in  order  that  it  can  pass  out.  One  word  explains 
these  various  passive  movements  of  the  foetus  in  birth,  and  that  is, 
accommodation;  during  the  whole  process  of  delivery  there  must  be 
adaptations  and  correspondences  between  the  passenger  and  the  passage 
through  which  it  is  transmitted. 

It  will  be  seen  in  the  study  of  the  mechanism  of  labor  that  there  is 
a  unity  of  character  in  all  labors,  no  matter  what  the  presentation  or 
position  of  the  foetus ;  provided  the  labor  be  natural,  occurring  at  term, 
and  the  foetus  be  living,  there  is  but  one  mechanism.1 

Before  studying  the  mechanical  phenomena  of  parturition  a  few  words 
must  be  said  in  regard  to  presentation  and  position.  As  has  been  before 
stated,  presentation  is  that  part  of  the  foetus  which  is  in  relation  with 
the  pelvic  inlet — that  which  presents,  offers  to  the  examining  finger  at 
the  mouth  of  the  womb,  or  that  part  through  which  the  pelvic  axis 
passes — and  our  first  inquiry  is  as  to  the  number  of  presentations. 
Baudelocque  described  twenty-three,  making  for  these  ninety-four  posi- 
tions ;  but  it  is  fortuuate  for  medical  students  that  authorities  do  not 
follow  him.  Madame  Lachapelle  was  the  first  to  show  that  the 
foetus  presented  by  the  cephalic,  or  the  pelvic  extremity,  or  by  the 
trunk.  But  these  presentations,  which  are  apparently  three,  really  in- 
clude five.  The  foetal  ovoid  usually  corresponds  with  the  uterine 
ovoid  ;  that  is,  the  foetus  occupies  a  longitudinal  situation  in  the  womb, 

x  i  Pajot. 


THE  MECHANICAL  PHENOMENA  OF  LABOR.  251 

and  hence  one  or  the  other  end  of  this  ovoid,  generally  the  head,  is  at 
the  pelvic  inlet.  If  the  head  be  inclined  forward  with  reference  to  the 
trunk,  that  is,  flexion  be  present,  and  this  is  the  case  generally,  the 
vertex — summit  or  top  of  the  head — presents,  and  hence  the  presenta- 
tion is  cranial.  On  the  other  hand,  if  deflexion — bending  back  of  the 
head,  extension — has  occurred,  the  face  presents,  and  the  presentation 
is  called  by  this  name  or  facial.  The  pelvis  of  the  foetus  may  be  in  the 
lower  segment  of  the  womb,  and  then  the  presentation  is  pelvic.  This 
presentation  .is  not  changed  by  any  change  of  position  of  the  lower 
limbs ;  the  pelvic  wedge  may  be  complete  or  decomposed — a  knee  or 
foot,  both  knees  or  both  feet,1  may  come  first,  but  no  matter  what  the 
.changes  of  position  of  these  parts,  none  of  the  mechanical  phenomena 
of  labor  are  needed  to  adapt  them  to  the  birth-canal,  for  they  are  small 
and  the  space  offered  by  the  maternal  pelvis  is  relatively  large ;  and  on 
the  other  hand  such  changes,  such  mechanism,  are  required  for  the  ex- 
pulsion of  the  breech.  Those  parts,  therefore,  are  included  under 
pelvic  presentation  which  may  be  defined  as  embracing  all  that  part  of 
the  fetus  below  a  horizontal  line  passing  from  one  to  the  other  iliac 
crest.  The  foetus  lying  transversely,  or  nearly  so,  may  present  some 
part  of  the  body  at  the  inlet ;  but  the  tendency  in  all  cases  is  for  one 
or  the  other  shoulder  to  descend  first,  so  that  presentation  of  the  body 
becomes  that  of  the  right  or  that  of  the  left  shoulder.  We  thus  have 
five  presentations,  cranial,  or  vertex,  facial,  pelvic,  right  and  left 
shoulder.  The  relations  which  the  presenting  part  of  the  foetus  has  to 
certain  fixed  points  of  the  inlet  give  the  position.  For  most  obstetri- 
cians these  points  are  the  sacro-iliac  joints  and  the  ilio-pectineal  emin- 
ences; they  are  the  terminations  of  the  oblique  diameters  of  the  inlet. 
It  follows,  therefore,  as  some  selected  point  of  reference  for  each  pres- 
entation is  in  relation  with  one  of  these  four  points  of  the  mother's 
pelvis,  sometimes  called  the  cardinal  points  of  Capuron,  the  position  is 
determined,  and  that  there  are  four  positions.  The  latter  part  of  this 
statement,  however,  only  applies  to  the  first  three  presentations  ;  each 
shoulder  presentation  has  only  two  positions,  as  will  be  explained  here- 
after. 

It  is  important  that  the  student  should  have  clearly  fixed  in  his  mind 
the  essential  difference  between*  presentation  and  position,  never  con- 
founding them,  never  using  one  as  a  synonym  for  the  other.  Presen- 
tation means  an  object,  but  position  is  a  relation ;  the  former  is  part  of 
the  foetus,  the  latter  a  temporary  relation  of  that  part  to  the  mother's 
pelvis;  position  is  an  accident,  the  property  of  a  presentation,  belonging 
to  it,  while  the  reverse  can  never  be  true.  Further,  it  is  important  not 
to  confound  position  as  belonging  to  presentation  with  position  as  be- 
longing to  the  foetus.  The  foetus  is  said  to  be  in  a  longitudinal  or  a 

1  Those  born  with  the  feet  first  were  called  Agrippas.  Roederer,  Elementa  Artis  Obstetricise,  ob- 
serves :  Quando  foetus  pedes  primi  ad  orificium  decidunt,  parlus  agripparum  oritur.  In  Pliny's 
Natural  History,  Book  Seventh,  the  following  passage  is  found  :  In  pedes  procedure  nascentem, 
contra  naturam  est :  quo  argumento  eos  appellavere  Agrippas,  ut  a>gre  partos.  This  explanation 
of  the  origin  of  the  term  has  been  accepted  in  the  New  Sydenham  Society's  Lexicon.  But  a  more 
probable  origin  is  given  by  Kraus,  Kritisch-etymologischeg  medicinisches  Lexikon ;  agrippa  is  from 
ay/wo?  iTTTTOf ,  feminine  aypia  iTnra,  for  the  nomadic  tribes  being  more  familiar  with  parturition 
as  it  occurred  in  mares,  gave  this  name  to  children  born  with  the  feet  first.  According  to  Schroder, 
there  was  a  superstition  that  those  born  thus  would  be  injurious  to  themselves  and  to  society,  and 
in  confirmation  of  the  belief  the  examples  of  Agrippa,  Nero,  Richard  III.,  and  Louis  XV.,  were 
cited. 


252 


PHYSIOLOGY  OF  LABOR. 


transverse  position  in  the  uterine  cavity ;  but  this  use  of  the  word  is 
very  different  from  that  in  connection  with  presentation.  The  four 
positions  belonging  to  each  of  the  three  presentations — cranial,  facial, 
and  pelvic — are  generally  designated  first,  second,  third,  and  fourth. 
Their  relative  frequency  is  not  settled — at  least  all  authorities  do  not 
agree — and,  therefore,  the  fitness  of  the  term  is  questionable  ;  but  as  the 
mechanism  of  labor  presents  some  slight  differences  according  as  the 
point  of  reference  of  the  presenting  part  is  in  the  right  or  left  side  of 
the  mother's  pelvis,  and  as  to  whether  it  is  anterior  or  posterior,  tht'se 
positions  will  be  distinguished  as  right  and  left  anterior,  and  right  and 
left  posterior.  In  vertex  or  cranial  presentation,  for  illustration,  this 
point  of  reference  is  the  occiput,  so  that  the  four  positions  for  this 
presentation  are  left  occipito-anterior,  left  occipito-posterior,  right  occi- 
pito-anterior,  and  right  occipito-posterior. 

FIG.  IDS. 


PALPATION  OF  UTERUS,  THE  HANDS  AT  ITS  SIDES. 

DIAGNOSIS.  The  diagnosis  of  presentation  and  position  is  made  by 
auscultation,  abdominal  palpation,  and  vaginal  touch.  The  first  two 
are  most  useful  in  pregnancy,  the  last  in  labor ;  the  former  cannot  be 
made  during  uterine  contraction,  and  the  third,  if  then  made,  the  mem- 
branes being  unruptured,  must  be  done  with  great  care  to  avoid  their 
rupture.  Nevertheless,  it  is  held  that  the  practitioner  who  makes  him- 
self expert  in  obstetric  palpation  and  auscultation,  can  reduce  to  a 
minimum  vaginal  examinations,  thus  lessening  the  liability  to  septic 
infection. 

VERTEX  PRESENTATION — DIAGNOSIS.  The  vertex  presents,  accord- 
ing to  Naegele,  in  93  to  95  per  cent.,  according  to  Spiegelberg  in  97  per 
cent.,  of  all  cases ;  the  causes  of  this  great  frequency  have  been  stated. 


THE  MECHANICAL  PHENOMENA  OF  LABOR. 


253 


In  making  a  diagnosis  by  external  examination  the  practitioner  should 
first  ascertain  that  the  foetus  is  not  placed  transversely,  but  occupies  a 
longitudinal  situation  in  the  womb — the  foetal  thus  corresponding  with 
the  uterine  ovoid.  He  learns  this  by  observing  the  general  form  of  the 
abdomen,  and  by  his  being  able  in  palpation  to  circumscribe  with  his 
hand  the  fundus  of  the  uterus  in  its  normal  position.  The  next  step  is 
to  find  which  end  of  the  foetal  ovoid  is  in  the  lower  segment  of  the 
uterus.  In  doing  this  the  obstetrician  places  his  hands  extended  and 
flat  upon  the  lower  part  of  the  sides  of  the  abdomen,  pressing  them 
somewhat  downward  at  the  ulnar  border  within  the  iliac  fossse;  then 
the  hands,  still  pressed  downward  and  moved  toward 'each  other,  will  in- 

FIG.  109. 


ASCERTAINING  THE  PRESENCE  OF  THE  FCETAL  HEAD  IN  LOWER  PART  OF  UTERUS. 

elude  the  foetal  head  if  it  be  in  the  lower  part  of  the  uterus,  and  if  it  has 
not  entered  the  pelvic  cavity.  Instead  of  at  first  placing  the  hands  upon 
the  sides  of  the  uterus,  they  may  be  in  contact  with  each  other  directly 
in  the  median  line  of  the  uterine  globe  just  above  the  pubes,  then  grad- 
ually separated,  pressing  the  ulnar  edge  of  each  downward  upon  the 
abdominal  wall  in  this  movement  until  they  pass  deeper,  when  they 
reach  the  borders  of  the  uterus,  and  the  lower  portion  of  this  organ  is 
then  included  between  them.  This  manipulation,  it  should  be  observed, 
is  of  chief  value  in  the  diagnosis  during  pregnancy.  A  single  hand  may 
often  be  successfully  used  in  abdominal  palpation  in  order  to  determine 
that  the  foetal  head  is  in  the  lower  part  of  the  uterus.  The  distinguish- 


254 


PHYSIOLOGY  OF  LABOR. 


ing  marks  of  the  foetal  head  in  palpation  are,  its  uniformity  of  shape, 
roundness,  hardness,  and  mobility;  if  the  head  be  in  the  pelvic  cavity, 
the  characteristic  last  stated  fails.  The  fact  that  the  presenting  part  is 
in  the  pelvic  cavity  in  the  latter  part  of  pregnancy,  or  early  in  labor, 
is  a  strong  proof  that  the  presentation  is  neither  the  pelvis  nor  the  face, 
but  the  vertex.  Further,  in  this  situation  one  hand  can  be  carried 
deeper  into  the  pelvis,  while  the  hand  on  the  other  side  of  the  pelvis 
meets  with  resistance  (Fig.  110);  the  occiput  therefore  is  upon  the  one 

FIG.  110. 


PALPATION  WHEN  THE  FCETAL  HEAD  is  IN  THE  PELVIS. 

side,  the  forehead  upon  the  other,  and  the  former  being  more  deeply 
situated  allows  the  descent  of  the  hand,  while  the  latter  prevents  such 
penetration.  Further,  when  the  occiput  is  found  the  position  of  the 
back  is  known,  for  it  must  be  upon  the  same  side  as  the  occiput.  The 
practitioner  may  then  verify  his  diagnosis  by  exploring  the  fundus  of 
the  uterus  in  which  the  pelvis  of  the  foetus  will  be  felt.  This  part  of 
the  child  is  recognized  as  a  large,  firm,  and  somewhat  round  body,  but 
it  lacks  the  uniform  shape,  the  solidity,  and  the  mobility  of  the  head ; 
moreover,  there  will  be  found  near  it  small  movable  bodies,  parts  of  one 
or  both  lower  limbs.  The  means  by  which  a  vertex  is  distinguished 
from  a  face  presentation  will  be  given  when  the  latter  is  considered. 
AUSCULTATION.  If  the  pulsations  of  the  foetal  heart  are  heard  most 


THE  MECHANICAL  PHENOMENA  OF  LABOR. 


255 


distinctly  below  the  transverse  line  (see  Fig.  105),  the  head  is  most 
probably  in  the  lower  part  of  the  uterus,  and  when  heard  to  the  left  of 
the  median  line  the  occiput  is  in  the  left  side  of  the  mother's  pelvis,  but 
if  upon  the  right,  the  occiput  is  in  the  right  side. 

INTERNAL  EXAMINATION.  The  method  of  vaginal  examination 
has  been  given  on  pages  189-192.  Again,  let  the  practitioner  be  cau- 
tioned against  the  danger  of  rupturing  the  membranes  by  pressure  upon 
the  bag  during  a  uterine  contraction  ;  he  should,  therefore,  usually 
defer  exploration  of  the  presenting  part  until  the  contraction  ceases.  If 
the  head  has  descended  into  the  pelvic  cavity,  the  finger  touches  a 
round,  hard,  projecting  body,  and  the  margin  of  the  mouth  of  the 
womb.  If  the  head  be  high  up,  only  a  small  portion  of  the  cranial 
vault  is  accessible  to  the  finger,  but  a  large  portion  may  be  reached  if 
the  other  hand  is  used  to  press  firmly  upon  the  hypogastrium  so  as  to 
force  the  head  further  into  the  pelvis.  When  theos  is  dilated  the  bones 
may  be  plainly  felt  through  the  foetal  membranes,  and  during  a  con- 
traction the  wrinkling  of  the  scalp  and  the  overriding  of  the  bones. 
If  labor  has  been  in  progress  some  time,  a  large  soft  mass,  the  caput 
succedaneum,  may  conceal  the  cranial  bones ;  but  by  pressing  firmly 
upon  this  mass  it  is  possible  the  finger  may  detect  beneath  it  a  bony 
surface,  or  else  the  finger  should  be  passed  within  the  os  so  as  to  touch 
parts  above  the  swelling. 


FIG.  111. 


LEFT  OCCIPITO-ANTERIOR  POSITION. 


POSITION.     Having  ascertained  that  the  presentation  is  cranial,  the 
position  is  next  to  be  ascertained.     The  occiput  being  the  point  of  refr 


256 


PHYSIOLOGY  OF  LABOR. 


erence,  in  this  presentation,  the  question  is  as  to  its  relation  to  some  one 
of  the  cardinal  points  of  the  inlet.  If  it  is  directed  toward  the  left 
ilio-pectineal  eminence,  the  position  is  left  occipito-anterior ;  if  to  the 
right,  right  occipito-anterior ;  if  to  the  left  sacro-iliac  joint,  left  occipito- 
posterior,  but  if  to  the  right,  right  occipito-posterior. 

The  same  means  are  available  for  the  diagnosis  of  position  as  for  the 
diagnosis  of  presentation,  viz.,  abdominal  palpation,  auscultation,  and 
vaginal  touch.  The  application  of  these  means  will  be  considered  with 
each  of  the  four  positions  given,  following  the  diagnosis  with  a  descrip- 
tion of  the  mechanism  of  labor. 

FIG.  112. 


PLACE  OF  GREATEST  INTENSITY  OF  FCETAL  HEAET-SODNDS  IN  LEFT  OCCIPITO-ANTERIOR  POSITION. 

FIRST.  LEFT  OCCIPITO-ANTERIOR  POSITIONS  (Figs.  Ill,  112).  As- 
certaining that  the  back  of  the  child  is  upon  the  leftside  of  the  mother's 
abdomen,  we  know  that  the  occiput  is  anterior  or  posterior  to  the  left 
side  of  the  pelvis ;  and  if  the  resistance  given  by  the  back  lessens  as 
the  hand  is  carried  farther  to  the  left  side,  the  occiput,  of  course,  which 
is  in  the  line  of  greatest  resistance,  points  to  the  ilio-pectineal  eminence 
— that  is,  the  position  is  left  occipito-auterior. 

Upon  auscultation  the  maximum  of  intensity  of  the  foetal  heart- 
sounds  is  found  about  the  middle  of  a  line  passing  from  the  left  ilio- 
pectineal  eminence  to  the  umbilicus  ;  some,  however,  have  the  line  start 
from  the  left  anterior  spinous  process  of  the  ilium. 

By  vaginal  touch  the  sagittal  suture  is  usually  felt  crossing  the  pelvic 
area  obliquely,  though  it  may  be  transverse,  and  a  little  nearer  the  pro- 
monotory  than  it  is  to  the  pubic  joint.  Having  found  the  suture,  the 


THE  MECHANICAL  PHENOMENA  OK  LABOR.  257 

finger  follows  it  either  to  the  right  or  to  the  left  until  the  anterior  or 
posterior  fontanelle  is  felt.  The  anterior  foutanelle  is  upon  the  right 
side  of  the  mother's  pelvis,  and  necessarily  the  occiput  is  upon  the  oppo- 
site side.  If  the  finger  follows  the  course  of  the  sagittal  suture  to  the 
posterior  fontanelle,  the  place  rather  than  the  presence  of  the  latter  is 
recognized  by  its  being  at  the  apex  of  a  depressed  triangle,  two  sides  of 
which  are  made  by  the  margins  of  the  parietal  bones  overriding  the 
occipital  bone,  these  sides  corresponding  with  the  bifurcation  of  the 
sagittal  suture.  The  occiput  is  at  or  near  the  left  ilio-pectineal  emi- 
nence. This  position,  left  occipito-anterior,  has  been  generally  called 
the  first,  and  it  is  the  first  in  frequency,  occurring  in  about  seventy  per 
cent. 

FIG.  113. 


FIRST  CRANIAL  POSITION.     OCCIPUT  AT  THE  LEFT  ILIO-PECTINEAL  EMINENCE,  FOREHEAD  AT  THE 

RIGHT  SACRO-ILIAC  JOINT. 

MECHANISM  OF  LABOR.  In  studying  this  mechanism  it  is  con- 
venient to  divide  it  into  stages,  or  times ;  but  it  is  to  be  remembered 
that  this  division  is  arbitrary,  for  some  of  these  stages  may  occur  con- 
temporaneously, or  some  may  be  absent,  but  in  such  cases  the  necessity 
for  them  does  not  exist,  the  factors  causing  them  are  wanting.  These 
different  stages  are,  in  presentation  of  the  vertex,  first,  flexion  ;  second, 
descent,  also  called  engagement,  or  progression  ;  third,  rotation ;  fourth, 
extension .;  fifth,  external  rotation  of  the  head  with  internal  rotation  of 
the  body ;  and,  sixth,  delivery  of  the  body.  Each  of  these  mechanical 
phenomena  is  to  be  studied  as  to  its  causes,  its  effects,  and  its  diagnosis. 

FLEXION.  This  is  bending  the  chin  toward  the  chest  so  that  it  rests 
on  it  when  flexion  is  complete;  it  is  essentially  rotation  of  the  head  upon 
a  transverse  axis.  In  considering  the  causes  of  flexion  the  natural 
position  of  the  head  must  be  regarded  as  predisposing  to  this  purely 
passive  movement,  for  it  is  already  somewhat  flexed,  and  the  flexion 
occurring  in  labor  is  simply  an  increase  in  this  state.  It  has  been  taught 
by  some  that  the  articulation  of  the  head  with  the  vertebral  column 
being  nearer  the  occiput  than  it  is  to  the  forehead,  the  force  passing 
through  that  column  acts  with  greater  power  upon  the  occiput,  causing 
it  to  descend  while  the  forehead  rises,  and  thus  flexion  is  increased. 
But  as  long  as  the  foetus  is  inclosed  in  the  membranes,  direct  pressure 
upon  it  does  not  occur ;  uterine  contractions  compress  the  ovum  at  all 
points  equally,  except  at  the  lower  segment  of  the  uterus  and  the  os 

17 


258 


PHYSIOLOGY  OF  LABOR. 


uteri  j  these  are  dilated  by  the  pressure,  and  the  force  is  transmitted  to 
the  foetus  through  the  intervening  liquor  amnii.  Even  after  the  rupture 
of  the  membranes  the  fcetal  head  may  so  effectually  plug  the  cervico- 
uterine  canal  that  only  a  small  quantity  of  amnial  liquor  escapes,  and 
therefore  direct  pressure  of  the  fundus  of  the  uterus  upon  the  upper 


FIG.  114. 


FIG.  115. 


ILLUSTRATING  THE  DIFFERENT  LENGTHS 
OF  THE  FRONTAL  ABM,  F  B,  AND  THE  OC- 
CIPITAL ARM,  B  O,  OF  THE  LEVER  MADE  BY 

THE  FtETAL  HEAD. 


EQUAL  RESISTING  FORCES  ACTING  THROUGH 
LEVERS  OF  UNEQUAL  LENGTH. 

portion  of  the  foetal  ovoid  falls.  It 
therefore  follows  that  the  direction  of 
the  uterine  force  cannot  be  deter- 
mined by  pressure  of  the  fundus  im- 
mediately upon  the  foetus  in  the  first 
stage  of  labor,  or,  indeed,  subse- 
quently before  the  free  discharge  of 
the  amnial  liquor. 

The  most  generally  received  ex- 
planation of  this  phenomenon  of 
labor  is  that  it  results  from  the  un- 
equal lengths  of  the  two  arms  of  a  lever  represented  by  the  head,  for 
that  part  of  the  head  in  front  of  the  vertebral  articulation  presents  a 
greater  surface  than  that  behind  this  articulation ;  in  other  words,  the 
anterior  arm  of  the  lever  is  longer  than  the  posterior — that  is,  the  dis- 
tance from  the  occipital  foramen  to  the  forehead  is  greater  than  from 
the  occipital  foramen  to  the  occiput.  Hence  equal  resistances  applied 
to  these  two  arms  necessarily  cause  the  anterior  or  longer  arm  to  rise, 
the  posterior  or  shorter  to  descend. 

In  the  subjoined  diagram  (Fig.  114),  taken  from  Hubert,  let  the  line 
F  i  represent  the  active  force;  N  A  and  M  B  equal  resistances ;  the  short 
arm  of  the  lever,  A  B,  that  is,  B  i,  must  descend,  for  the  resistance,  N  A, 
is  the  more  powerful,  because  acting  through  the  long  arm,  A  i. 

Fig.  115,  taken  from  Ribemont,  shows  the  much  greater  length  of  the 
anterior  than  of  the  posterior  arm  of  the  lever  represented  by  the  head ; 
F  B  is  the  frontal,  and  B  O  the  occipital  arm ;  the  sum  of  resistance- 


THE  MECHANICAL  PHENOMENA  OF  LABOR.  259 

pressure  to  which  the  former  is  subjected  must  much  exceed  that  which 
opposes  the  descent  of  the  latter. 

Another  principle  in  mechanics  has  been  brought  forward  by  Hubert  as  con- 
tributing to  flexion.  If  a  propulsive  force  be  exercised  centrally  upon  a  mobile, 
and  there  be  resisting  forces  not  directly  opposite  each  other,  but  at  different 
levels,  rotation  of  the  mobile  occurs ;  thus,  flexion  of  the  head,  which,  as  has 
been  before  stated,  is  simply  rotation  of  the  head  upon  a  transverse  axis,  is  fre- 
quently completed  when  the  os  uteri  is  almost  entirely  dilated  so  that  the  occiput 
has  escaped,  and  the  resistance  of  the  os  acts  upon  the  forehead  and  the  face, 
causing  flexion. 

According  to  Lahs,1  the  entire  expulsive  force  of  the  uterus  acts  upon  the 
foetal  head  in  a  line  perpendicular  to  the  surface  of  what  he  terms  "the  girdle  of 
contact" — that  is,  the  part  of  the  birth-canal  for  the  time  resisting  the  advance 
of  the  head.  "The  head  is  a  wedge,  whose  surfaces  are  found  through  the  tan- 
gents made  on  those  points  of  the  head's  surface  directly  in  relation  with  the 
girdle  of  contact."  That  part  of  the  head  whose  tangent  makes  the  smaller 
angle  with  the  perpendicular  line  of  expulsion  must  descend  first.  This  smaller 
angle  is  made  at  the  occiput,  and  therefore  this  descends  and  flexion  results. 

Whatever  theory  of  flexion  may  be  adopted,  the  movement  itself  is 
essentially  one  of  accommodation,  of  adaptation  of  the  foetal  head  to  its 
passage  through  the  birth-canal.  The  head  entered  the  inlet  with  the 
occiput  at  the  left  ilio-pectineal  eminence,  and  the  forehead  at  the  right 
sacro-iliac  joint,  that  is,  the  occipito-frontal  diameter  was  in  relation 
with  the  right  oblique  of  the  inlet,  and  the  bi-parietal  with  the  left 
oblique ;  hence  a  circumference  of  the  foetal  head  whose  diameter  is  the 
occipito-frontal  is  in  relation  with  the  circumference  of  the  inlet.  The 
long  diameter  is  not  perpendicular,  but  oblique  to  the  plane  of  the  inlet; 
besides  this  obliquity  it  was  asserted  by  Naegele  that  the  head  entered 
inclined  on  the  anterior  parietal  bone,  so  that  the  right  parietal  protub- 
erance was  somewhat  lower  than  the  left,  and  this  inclination  was  known 
as  Naegele's  obliquity,2  but  most  obstetricians  reject  it ;  at  least  its  con- 
sideration may  well  be  omitted  in  the  study  of  the  mechanism  of  normal 
labor.  The  effect  of  flexion  is  not  only  to  bring  the  long  diameter  of 
the  foetal  head  more  or  less  completely  in  correspondence  with  the  axis 
of  the  inlet,  but  to  present  a  less  circumference  of  the  head  to  the  cir- 
cumference of  the  inlet,  for  as  the  chin  comes  to  the  sternum,  not  the 
occipito-froutal  diameter,  but  a- shorter  one,  the  suboccipito-bregmatic, 
is  in  relation  with  the  left  oblique  of  the  inlet.  Remembering  that 
flexion  is  a  movement  of  accommodation,  it  occurs  when  and  where 
such  accommodation  is  necessary.  It  may,  therefore,  take  place  at  the 
inlet,  in  the  lower  portion  or  at  the  mouth  of  the  uterus,  or  at  the  peri- 
neal  floor,  or,  finally,  it  may  not  occur  because  the  small  size  of  the 
foetus,  or  the  great  size  of  the  pelvis,  the  slight  resistance  of  the  os  uteri, 
or  of  the  pelvic  floor  renders  it  unnecessary. 

Flexion  not  only  substitutes  a  less  foetal  head  plane,  but,  according  to 
Pajot,3  prior  to  its  occurrence  there  is  a  great  loss  of  force  from  its  trans- 
mission through  a  flexible,  vacillating  rod,  to  which  he  compares  the 
foetus,  the  mobility  existing  especially  at  the  articulation  of  the  head 


Die  Theorie  der  Geburt. 

The  obliquity  of  Solayi 
imeters.  and  Roederer's  tx 
3  Dictionnaire  Encyclopedique  des  Sciences  Medicales. 


2  The  obliquity  of  Solayres  refers  to  the  head  entering  the  pelvic  inlet  in  one  of  its  oblique 
diameters,  and  Roederer's  to  the  complete  flexion  of  the  head  on  the  chest. 


260  PHYSIOLOGY  OF  LABOR. 

with  the  trunk;  but  when  the  head  is  firmly  pressed  upon  the  thorax 
it  is  found  favorably  disposed  to  participate  in  the  impulsion  impressed 
upon  the  general  mass  of  the  foetus.  Further,  flexion  facilitates  mould- 
ing of  the  head  so  that  it  is  adapted  to  the  birth-canal.  The  diagnosis 
of  flexion  is  made  by  the  recognition  of  the  relative  position  of  the  fon- 
tanelles;  at  the  beginning  of  labor  they  are  almost  upon  the  same  plane, 
the  anterior  a  little  higher  than  the  posterior;  as  flexion  occurs,  the 
former  recedes  with  the  ascent  of  the  forehead,  but  the  latter  descends 
with  the  descent  of  the  occiput,  and  when  the  anterior  is  very  high,  and 
consequently  the  posterior  very  low,  flexion  is  complete,  but  if  the  two 
are  equally  accessible,  it  has  not  occurred. 

DESCENT.  The  uterine,  reinforced  by  abdominal,  contractions  now 
compel  the  head  to  descend  into  the  pelvic  cavity;  the  axis  of  the  uterus 
corresponding  with  that  of  the  upper  part  of  this  cavity  there  is  no  loss 
of  force,  and  hence  if  there  be  the  proper  relation  between  the  fcetal 
head  and  the  canal,  the  latter  presenting  only  its  usual  resistance,  and 
the  driving  force  normal,  there  is  no  delay  in  the  descent  of  the  head. 
The  head  planes  are  parallel  with  the  pelvic  planes  during  the  first  part 
of  the  descent,  and  then  in  consequence  of  the  greater  resistance  of  the 
posterior  than  of  the  anterior  pelvic  wall,  this  synclitism — that  is,  the 
parallelism  between  the  planes  of  the  child's  head  and  the  transverse 
planes  of  the  mother's  pel  vis — ceases,  though  Dr.  Hodge  and  some  other 
obstetricians  taught  that  it  continued  during  the  entire  descent. 

A  movement  called  levelling  is  described  by  some  as  occurring  when  the  head 
has  descended  so  that  the  occiput  is  at  the  lower  margin  of  the  ischio-pubic  fora- 
men, :and  the  bregma  is  at  the  second  bone  of  the  sacrum;  by  this  movement, 
essentially  a  lessening  of  flexion,  the  anterior  fontanelle  becomes  more  accessible, 
and  the  occipito-frontal  diameter  is  in  relation  with  the  right  oblique  of  the  pelvic 
canal.  This  phenomenon  is  not  constant,  does  not  contribute  when  present  to 
the  progress  of  labor,  and  therefore  may  be  dismissed  from  further  consideration. 

The  progress  .of  the  second  stage  of  labor  is  ascertained  by  measuring 
with  the  finger  the  distance  of  the  head  from  the  vulval  opening.  This 
measurement  is  most  conveniently  made  by  using  the  thumb  as  an  index 
to  the  measuring-rod,  the  linger.  Two  errors  are  to  be  guarded  against : 
First,  mistaking  a  caput  succedaneum  for  advance  of  the  head ;  and, 
second,  the  head  may  descend  still  inclosed  in  the  uterus,  whose  lower 
segment  may  be  so  thinned  that  without  great  care  the  examiner  believes 
he  directly  touches  the  head,  and  may  conclude  that  the  labor  is  much 
further  advanced  than  it  really  is. 

ROTATION.  This  is  a  movement  by  which  the  occiput  turns  in  front, 
the  entire  trunk  participating  in  the  rotation.  The  expulsive  power 
driving  the  head  down,  the  occiput  is  forced  to  escape,  but  only  anteriorly 
is  there  a  gap  in  the  pelvic  wall,  and  to  this  gap  the  ischio-pubic  ramus 
— bevelled,  flaring — invites ;  the  occiput  descends  with  a  pain,  boring, 
feeling  its  way,  receding  in  the  interval  between  pains,  until  finally  driven 
by  a  vigorous  pain  it  passes  the  bony  margin  at  the  latero-anterior  part 
of  the  pelvis,  and  there  is  no  subsequent  recession,  but  it  sweeps  forward 
toward  the  centre  of  the  vulval  opening,  and  the  sub-occipital  region 
comes  under  the  pubic  symphysis.  As  observed  by  Dr.  Ritchie,1  in 

1  Medical  Times  and  Gazette,  1865. 


THE  MECHANICAL  PHENOMENA  OF  LABOR.  261 

some  cases  the  head  escapes  all  pivot  movement  in  the  pelvis,  but  comes 
down  obliquely  upon  the  perineum,  and  suddenly  wheels  round  when  it 
is  on  the  point  of  escaping  from  the  vulva,  the  rotation  resulting  from 
the  shape  of  the  perineum  which,  attached  on  either  side,  yields  most  in 
the  median  line,  thus  forming  a  gutter  in  which  the  head  is  best  accom- 
modated, lying  not  obliquely  but  antero-posteriorly.  When  rotation  of 
the  head  occurs  in  the  pelvic  cavity,  while  the  occiput  comes  in  front, 
there  is  a  reverse  movement  of  the  sinciput  which  turns  into  the  sacral 
cavity. 

Obstetric  authorities  have  devoted  much  attention  to  the  study  of  the 
causes  of  rotation,  and  have  greatly  differed  as  to  them.  Baudelocque 
referred  this  phenomenon  to  the  inclined  planes  of  the  pelvis,  the  anterior 
determining  rotation  into  the  pubic  arch,  the  posterior  rotation  into  the 
sacral  cavity.  This  view  probably  has  had  more  adherents  than  any 
presented  since  ;  some  have  modified  it  by  changing  the  position  of  the 
arbitrary  lines,  separating  the  anterior  from  the  posterior  planes,  but 
still  essentially  their  teaching  has  been  that  of  Baudelocque ;  this  was 
true  especially  of  the  teaching  of  Hodge.  But  the  accepted  explanation 
of  the  cause  of  rotation,  while  satisfactory  so  far  as  anterior  positions  of 
the  occiput  are  concerned,  failed  as  to  posterior  positions,  for  in  these,  too, 
as  first  proved  by  Naegele,  the  occiput  in  most  cases  rotates  anteriorly. 
Perinea!  resistance,  according  to  some,  is  the  cause  of  anterior  rotation; 
but,  as  observed  by  Charpentier,  this  cannot  be  the  sole  cause,  or  the 
movement  ought  never  to  fail  in  prirniparae,  for  in  them  the  perineum 
is  remarkably  resistant.  The  unequal  lengths  of  the  two  arms  of  the 
head  lever  is.  according  to  others,  the  cause,  for  the  occipital  arm  being 
the  shorter  the  occiput  moves  in  the  direction  of  least  resistance. 

The  law  of  mechanics,  which  Hubert  has  applied  to  the  explanation 
of  flexion,  has  its  application  here  also.  When  a  mobile  is  subjected  to 
resisting  forces,  which  are  not  directly  opposite,  they  tend  to  impress 
upon  it  a  movement  of  rotation.  While  some  assert  that  this  explana- 
tion holds  only  for  the  rotation  which  occurs  in  anterior  positions,  it 
may  be  shown  in  the  discussion  of  the  mechanism  of  labor  in  posterior 
positions  that  the  anterior  rotation  which  then  occurs  can  also  be  thus 
explained.  Pajot,  rejecting  all  geometrical  explanations,  finds  the  just 
idea  of  the  causes  of  rotation  in  the  immutable  principle  of  mechanics 
which  has  been  formulated  in  what  is  known  as  his  law  (previously 
stated) :  "  The  indispensable  condition  for  the  execution  of  this  law  is  that 
the  power,  the  volume  of  the  content,  and  the  capacity  of  the  container 
must  be  proportional."  If  the  foetus  be  too  large,  insurmountable  ob- 
stacles are  presented  to  its  rotation  ;  if  it  be  too  small,  there  is  no  invita- 
tion to  turn,  and  when  the  foetus  and  the  passage  are  in  due  proportion, 
turning  may  fail  for  want  of  sufficient  expulsive  force.  The  results  of 
rotation  are  that  the  suboccipito-bregmatic  diameter,  which  corresponded 
with  the  right  oblique  of  the  mother's  pelvis,  is  now  in  relation  with 
the  antero-posterior  of  the  outlet,  and  the  biparietal  with  the  transverse, 
and  the  shoulders — as  the  body  participated  in  the  rotation — descended 
in  the  pelvis  with  the  bisacromial  diameter  in  relation  with  its  transverse 
diameter.  Rotation  is  known  to  have  taken  place  by  the  position  in 
which  the  occiput  is  found — that  is,  directly  in  front ;  in  some  cases  the 


262  PHYSIOLOGY  OF  LABOR. 

movement  may  be  recognized  during  its  occurrence  by  a  finger  placed 
upon  the  occiput. 

EXTENSION.  The  third  of  the  mechanical  phenomena  of  labor  is  a 
movement  of  the  head  directly  the  reverse  of  the  first;  whereas  the 
head  then  rotated  forward  on  its  transverse  axis,  so  that  the  chin  came 
to  rest  on  the  sternum — it  now  rotates  backward,  and  the  chin  recedes 
from  the  sternum,  that  is,  deflexion  or  extension  occurs.  In  this  move- 
ment the  nape  of  the  neck  presses  the  subpubic  ligament,  the  shoulders 
are  transverse,  and  close  behind  the  pubic  arch,  so  that  the  occiput  can 
advance  no  further  in  a  direct  line ;  meanwhile  expulsive  action  continu- 
ing is  met  by  the  resistance  of  the  perineum,  and  the  resultant  diagonal 
force  is  in  the  axis  of  the  prolonged  birth-canal ;  the  expulsive  force 
cannot  act  directly  upon  the  occiput,  but  only  upon  the  long  arm  of  the 
head  lever,  thus  forcing  the  chin  to  descend  ;  according  to  Pajot,  the 
occipito-mental  diameter  represents  a  lever  of  the  third  order,  the  fulcrum 
being  at  the  pubic  arch,  the  resistance  at  the  pelvic  floor,  and  the  power 
between  the  two,  that  is,  at  the  occipital  foramen.  But  extension  or 
rotation  backward  of  the  foetal  head  may  also  be  explained  as  the  result 
of  a  driving  force  met  by  two  resisting  forces  acting  upon  the  foetal  head 
at  different  planes,  or  two  unequal  forces,  even  if  acting  in  the  same 
plane.  We  have  first  the  driving  force  of  uterine  and  abdominal  con- 
tractions; the  perineum  resists,  and  -there  is  also  resistance  at  the 
pubic  arch,  but  the  former  resistance  being  less  than  the  latter,  rotation 
results — the  head  is  rolled  out  of  the  vulval  opening,  the  bregma,  the 
forehead,  and  the  face  appearing  successively  from  behind  the  perineum, 
the  occiput  continuing  to  move  in  a  curve  over  the  pubic  symphysis, 
the  successive  radii  of  this  curve  being  the  several  suboccipital  diame- 
ters.1 The  longest  of  these  diameters  is  the  suboccipito- frontal,  and  the 
vulval  opening  is  of  course  in  greatest  danger  of  being  torn  during  the 
passage  of  the  head  circumference  corresponding  with  this  diameter. 
The  progress  of  this  stage  of  labor  is  known  by  the  emergence  of  a 
greater  part  of  the  foetal  head  at  each  expulsive  effort,  and  its  comple- 
tion by  the  dropping  down  of  the  head  in  front  of  the  anus,  and  by 
the  retraction  of  the  perineum. 

EXTERNAL  ROTATION  OF  THE  HEAD  WITH  INTERNAL  ROTATION 
OF  THE  BODY.  In  some  cases  just  after  the  head  drops  down — face 
below,  occiput  above,  there  is  a  change  of  the  head  to  an  oblique  posi- 
tion :  this  movement  is  called  restitution,  and  it  takes  place  when  in 
internal  rotation  the  body  did  not  follow  the  head  in  this  movement, 
but  a  twist  in  the  neck  occurred,  and  now  the  head  is  restored  to  its  nor- 
mal position  with  reference  to  the  trunk.  Restitution  is  oftener  seen  in 
occipito-posterior  than  in  occipito-anterior  positions,  but  even  in  the 
former  it  is  not  frequent,  for  with  perfect  flexion  the  foetus  is  so  com- 
pacted together  that  head  and  trunk  make  one  mass,  and  move  together. 
In  most  cases  no  such  movement  as  restitution  is  recognized,  but  the 

1  This  hitherto  generally  received  explanation  of  the  expulsion  of  the  foetal  head  has  recently 
been  controverted  by  Berry  Hart,  who,  denying  extension,  claims  that  progression,  or  translation 
of  the  head,  occurs,  occiput  and  sinciput  simultaneously  advancing.  He  attributes  that  which  he 
calls  the  erroneous  idea  of  extension  to  the  fact  that  "  the  attendant,  while  the  patient  lay  on 
her  left  side,  watched  the  passage  of  the  fcetal  head  from  behind,  saw  more  of  the  anterior  portion 
of  the  head  appear,  and  accounted  for  it  by  extension."  Hart's  opinion  will  be  referred  to  on  a 
future  page. 


THE  MECHANICAL  PHENOMENA  OF  LABOR.  263 

head  remains  motionless  after  dropping  down  with  the  end  of  the  fourth 
stage  of  labor,  until  a  new  expulsive  effort  occurs,  and  then  it  moves 
through  the  fourth  of  a  circle  so  that  the  occiput  points  to  the  mother's 
left  thigh,  and  the  face  to  her  right  thigh.  A  simple  law  may  be  given 
in  this  connection — the  occiput  always  points  to  that  thigh  correspond- 
ing to  the  side  of  the  pelvis  in  which  it  was  before  the  delivery  of  the 
head,  and  thus  if  the  occiput  was  in  the  left  side  of  the  pelvis,  no  mat- 
ter whether  posterior  or  anterior,  it  will  point  to  the  left  thigh.  The 
external  rotation  of  the  head  indicates  the  internal  rotation  of  the 
shoulders;  they  descended  into  the  pelvis,  the  bisacromial  diameter  in 
relation  with  the  left  oblique  of  the  inlet ;  the  body  rotating  with  the 
head  the  bisacromial  became  transverse,  but  as  delivery  in  this  position 
is  impossible,  body  rotation,  which  is  indicated  by  external  rotation  of 
the  head,  takes  place,  so  that  the  right  shoulder  is  behind  the  pubic 
joint  and  the  left  is  in  the  sacral  cavity. 

EXPULSION  OF  THE  BODY.  Expulsive  efforts  continuing,  the  pubic 
shoulder  passes  out  first — it  has  the  shorter  distance  to  traverse,  and 
it  represents  the  occiput  which  was  delivered  first — and  the  superior 
part  of  the  trunk  pivots  upon  the  arm  just  below  the  shoulder,  while 
the  sacral  shoulder  sweeps  the  sacral  curve  and  follows  the  course  of  the 
distended  perineum,  the  perineal  pressure  and  the  direction  of  the  canal 

FIG.  116. 


EXTERNAL  ROTATION  OF  HEAD  IN  FIRST  POSITION. 

causing  incurvation  of  the  body  upon  its  lateral  plane;  the  sacral  shoul- 
der is  finally  delivered,  and  the  arm  quickly  follows,  and  then  the  pubic 
arm  passes  out,  and  the  lateral  curvature  of  the  body  is  at  an  end.  Just 
as  the  nape  of  the  neck  was  fixed  at  the  subpubic  ligament  in  delivery 
of  the  head,  so  is  the  upper  part  of  the  pubic  arm  situated  in  delivery 
of  the  superior  portion  of  the  trunk ;  delivery  of  the  head  was  effected 
through  extension,  but  that  of  the  shoulders  by  flexion,  the  lateral  in- 
curvation of  the  body  is  simply  the  analogue  of  extension  of  the  head. 

Authorities  differ  as  to  which  shoulder  is  delivered  first,  and  some  end  the  con- 
troversy by  asserting  a  simultaneous  delivery.  The  illustration  just  presented 
shows  that  the  upper  shoulder  has  passed  the  pubic  arch,  while  the  under  one 


264  PHYSIOLOGY  OF  PREGNANCY. 

is  still  hidden  by  the  perineum ;  although  Dr.  Hodge,  from  whose  work  the  dia- 
gram is  taken,  taught  that  they  escaped  at  the  same  time,  the  statement  is  con- 
tradicted by  it.  Cazeaux  held  that  in  primiparre  the  delivery  is  as  stated  in  the 
text,  but  not  in  the  parous  when  the  perineum  has  been  torn.  But  this  is  a  con- 
cession of  the  very  point  at  issue,  and  we  may  say  with  Pajot  that  in  the  normal 
mechanism  of  labor  the  pubic  shoulder  is  first  delivered. 

The  expulsion  of  the  rest  of  the  body  rapidly  follows  that  of  the 
shoulders,  the  trunk  making  somewhat  of  a  spiral  movement ;  if  the 
hips  are  very  large,  there  may  be  delay,  and  the  same  mechanism  occurs 
as  in  the  delivery  of  the  shoulders. 

THE  ROTATIONS.  In  the  preceding  description  of  the  mechanism  of  labor 
the  rotations  that  have  been  stated  are  two,  but  there  is  also  a  third  of  the 
mechanical  phenomena  of  labor  that  is  essentially  a  rotation,  for  flexion  of 
the  head  is  simply  the  turning  of  the  head  upon  a  transverse  axis ;  so,  too,  the 
head  rotates  in  its  expulsion,  only  the  rotation  is  directly  the  opposite  of  that 
which  occurred  in  complete  flexion. 

Fritsch1  describes  five  rotations.  The  first  of  these  is  the  lateral  turning  of 
the  head  in  entering  the  pelvis,  so  that  the  anterior  parietal  is  lower  than  the 
posterior,  the  sagittal  suture  being  nearer  the  promontory  than  it  is  to  the  anterior 
pelvic  wall.  This  position,  known  as  Naegele's  obliquity,  according  to  him, 
results  from  the  projection  of  the  promontory,  and  from  there  being  no  similar 
resistance  at  the  anterior  pelvic  wall. 

But  this  obliquity,  while  a  constant  feature  in  the  flat  pelvis,  is  by  no  means, 
according  to  most  obstetricians,  a  frequent  phenomenon  in  a  normal  pelvis,  and 
therefore  its  consideration  may  be  omitted. 

Of  the  other  rotations,  the  only  one  considered  in  this  note  is  the  anterior  rota- 
tion of  the  occiput  into  the  pubic  arch.  This  rotation  has  given  rise  to  much 
discussion,  many  explanations  have  been  offered,  and  by  no  means  the  last  word 
has  been  said.  It  is  impossible  to  mention  all  the  theories  of  its  causes.  Werth'2 
explains  that  this  movement  occurs  because  the  anterior  pelvic  wall  and  the  region 
of  the  pubic  arch  offer  no  important  resistance,  while  laterally  and  behind  notable 
obstruction  opposes.  Fritsch  refers  to  the  frontal  bone  pressing  against  the 
anterior  lateral  part  of  one-half  the  pelvis,  and  there  an  oblique  plane  tends  to 
cause  a  movement  posteriorly ;  then  the  form  of  the  horizontal  pelvic  plane  is 
such  that  there  are  two  angles  presented,  one  anterior  and  acute,  the  other  pos- 
terior and  obtuse ;  the  forehead  must  turn  into  the  opening  of  the  latter. 

Some  have  attributed,  either  wholly  or  in  chief  part,  the  turning  of  the  occiput 
forward  to  the  action  of  the  levatores  ani ;  this  was  the  teaching  of  my  prede- 
cessor in  Jefferson  Medical  College,  the  late  Dr.  Ellerslie  Wallace,  and  it  has 
also  been  held  by  some  of  the  most  eminent  among  German  obstetric  teachers. 

It  is  not  remarkable  that  the  rotation  of  the  head  internally,  like  its  rotation 
externally,  has  been  by  several  authorities  explained  as  resulting  from  a  move- 
ment of  the  body ;  as  external  rotation  of  the  head  tells  of  internal  rotation  of 
the  shoulders  or  trunk,  so  it  is  claimed  that  this  results  from  a  similar  movement 
of  the  body.  Many  eminent  obstetricians  uphold  this  view ;  among  these  may 
be  mentioned  Litzmann,  Kehrer,  and  Olshausen.  The  last  has  stated  that  in 
consequence  of  the  increased  flattening  of  the  uterus  by  contractions  the  back 
of  the  child  is  pushed  from  a  lateral  to  a  front  position,  because  of  more  room 
anteriorly,  necessarily  then  the  child's  head  is  turned  so  that  the  sagittal  suture 
is  antero-posterior.  Ahlfeld 3  criticises  this  view  on  two  grounds :  First,  rotation 
of  the  head  occurs  in  the  first  of  twins  when  the  uterus  is  not  flattened,  and, 
second,  it  occurs,  too,  in  a  head-last  labor. 

Ostermann,  in  a  recent  monograph,  Die  Cardinallebewegung  des  Geburtsmechan- 
ismus,  regarding  previous  explanations  as  not  completely  satisfactory,  endeavors 
to  make  good  a  new  theory  applicable  to  all  cases.  He  starts  with  presenting 
the  three  factors  to  be  considered,  namely,  the  expulsive  force,  the  canal  and  its 

1  Klink  der  Geburtshtilflichen  Operationen.    1894. 

«  MUller's  Handbuch  der  Geburtshttlfe.    I.  Band.    1888. 

8  Lehrbuch  der  Geburtshilfe.    18&4. 


THE  MECHANICAL  PHENOMENA  OF  LABOR.  265 

form,  and  third,  the  foetus  and  its  form.  The  rotation  which  is  being  especially 
considered,  he  attributes  to  the  uterine  contractions  which  place  the  shoulders 
in  a  transverse  position  at  the  pelvic  inlet. 

The  main  factor  in  rotation  depends  chiefly  upon  the  greater  flexibility  of  the 
antero-posterior  and  the  less  lateral  flexibility  of  the  vertebral  column. 

Osterman  concludes  his  paper  by  saying  :  "  We  have  endeavored  to  show  the 
influence  of  both  factors,  the  simple  flexion  of  the  lower  pole  toward  the  opening 
of  the  canal,  and  the  invariable  preponderance  of  the  antero-posterior  flexibility 
of  the  vertebral  column.  It  may  seem  that  a  more  important  influence  is  ascribed 
to  the  foetus  than  is  the  actual  fact.  This  appears  to  us  to  rest  upon  the  natural 
conditions.  Should  we  wish  briefly  to  describe  the  transmission  of  the  foetus,  we 
would  say :  The  foetus  winds  itself  through  the  birth-canal  throughout ;  but  this 
expression  must  not  be  understood  to  suggest  an  active  participation.  In  this 
strong  and  general  statement  the  assertion  that  the  anterior  rotation  of  the  small 
fontanelle  is  referred  to  the  turning  of  the  deepest  part  (Schroeder)  seems  un- 
necessary, at  least  it  is  not  lost  in  a  chaos  of  details.  Admitting  the  previously 
considered  factor,  so  we  believe  it  may  be  applied  for  the  explanation  of  all 
cases  of  rotation. " 

The  anterior  rotation  of  the  occiput  may  occur,  as  many  obstetricians  have 
observed,  before  the  head  rests  upon  the  pelvic  floor,  and  therefore  this  cause, 
offered  by  many  as  explaining  the  mechanism  of  the  movement,  cannot  be 
admitted  a  constant  factor. 

RIGHT  OCCIPITO-ANTERIOE  POSITION.  In  this  position,  which  is 
the  rarest  of  the  four,  the  occiput  is  in  the  inlet,  at  the  right  ilio-pecti- 
neal  eminence,  and  the  forehead  at  the  left  sacro-iliac  joint,  the  child's 
back  is  in  the  right  and  anterior  portion  of  the  uterus,  and  the  limbs  in 
the  left  and  posterior  portion.  By  abdominal  palpation  the  head  is 
found  in  the  lower  segment  of  the  uterus,  and  the  back  in  the  situation 
mentioned  ;  the  hand  passes  more  deeply  in  the  pelvis  upon  the  right 
side  than  upon  the  left.  Upon  auscultation  the  maximum  of  intensity 
of  the  fetal  heart-sounds  is  found,  according  to  Depaul,  at  the  middle 
of  a  line  passing  from  the  right  ilio-pectineal  eminence  to  the  umbilicus 
(see  Fig.  105 ;  this  maximum  is  found  at  (7),  but  according  to  Ribe- 
mont  upon  the  median  line,  sometimes,  indeed,  a  little  to  the  left  of  it. 
Digital  examination  confirms  the  diagnosis  of  a  vertex  presentation, 
and  the  sagittal  suture  is  found  to  be  in  the  left  oblique  diameter  of  the 
inlet,  the  occiput  at  the  right  ilio-pectineal  eminence,  and  the  forehead 
at  the  left  sacro-iliac  joint. 

The  mechanical  phenomena  are  the  same  as  those  which  have  been 
described  as  taking  place  in  a  left  occipito-anterior  position.  First, 
flexion  occurs,  a  process  of  accommodation,  an  adaptation  of  the  pre- 
senting part  to  the  birth-canal,  by  substituting  a  smaller  head  circum- 
ference to  the  pelvic  area,  a  lessening  of  the  foetal  part  which  descends 
first.  Descent  follows,  and  then  rotation  ;  but  the  occiput,  instead  of 
rotating  from  left  to  right,  now  rotates  from  right  to  left  into  the  pubic 
arch.  Extension  occurs  next,  for  direct  progression  of  the  occiput  is 
impossible,  because  it  is  held  back  by  the  shoulders  lying  transversely, 
but  indirect  advance  occurs  by  the  occiput  tending  to  approach  the  back, 
the  chin  departing  from  the  chest,  and  the  entire  head  is  rolled  out  of 
the  vulval  opening ;  the  head  thus  rotates  backward  upon  its  transverse 
axis  in  deflection,  just  as  it  rotated  forward  in  flexion.  After  the  birth 
of  the  head  it  rotates  externally  as  the  sign  and  the  effect  of  internal 
rotation  of  the  body,  but  the  occiput  now  is  directed  to  the  mother's 
right  thigh,  the  face  to  her  left,  which  is  the  reverse  of  the  situation  of 


266  PHYSIOLOGY  OF  LABOR. 

these  parts  of  the  head  in  a  left  occipital  position.  By  the  direction  in 
which  this  external  rotation  occurs  the  student  may  correct  or  confirm 
the  diagnosis  of  position  made  at  the  beginning  of  labor.  Finally, 
delivery  of  the  body  takes  place  in  the  manner  described  for  a  left 
occipito-anterior  position. 

RIGHT  OCCIPITO-POSTERIOR  POSITION.  This  is  next  in  frequency 
to  the  position  first  described  ;  it  is  that  position  reversed,  and  hence  the 
occipito-frontal  and  the  biparietal  diameters  hold  the  same  relations  to 
the  two  oblique  diameters  of  the  inlet  that  they  did  in  left  occipito- 
anterior  position.  The  former  of  these  foetal  diameters,  which  it  will 
be  remembered  is  the  longer,  avoids  the  left  oblique  of  the  inlet,  which 
is  practically  the  shorter  of  the  two  pelvic  measurements,  because  of 
the  presence  of  the  rectum  upon  the  left  side.  The  occiput  is  at  the 
right  sacro-iliac  joint,  and  the  forehead  at  the  left  ilio-pectineal  eminence ; 
the  back  of  the  child  is  posterior  and  to  the  right,  the  limbs  anterior 
and  to  the  left  side  of  the  mother's  abdomen. 

FIG.  117. 


RIGHT  OCCIPITO-POSTERIOR  POSITION. 


Palpation  proves  the  presence  of  the  head  in  the  lower  part  of  the 
uterus;  the  hand  can  pass  more  deeply  in  the  right  side  of  the  pelvis 
than  in  the  left ;  in  the  latter  it  is  arrested  by  the  projecting  forehead 
at  the  ilio-pectiueal  eminence.  The  dorsal  plane  of  the  foetus  can  be 
more  readily  recognized  if  the  woman  lies  upon  her  left  side.  The 
maximum  of  intensity  for  the  foetal  heart-sounds  is  in  a  line  passing 
from  the  right  sacro-iliac  joint  to  the  umbilicus.  Digital  examination 
shows  that  the  anterior  foutanelle  is  in  front  and  to  the  left,  the  posterior 
fontanelle  to  the  right  and  behind,  while  the  sagittal  suture  is  in  the 
right  oblique  of  the  inlet. 

The  mechanical  phenomena  of  labor  are  in  almost  all  cases  the  same 
as  have  been  described,  and  therefore  need  not  be  detailed.  One  of 
these,  however,  requires  special  study — that  of  internal  rotation.  In 
occipito-anterior  positions  the  occiput  rotated  only  through  a  little  more 
than  one-eighth  of  a  circle  in  order  to  be  placed  in  the  pubic  arch,  but 


THE  MECHANICAL  PHENOMENA  OF  LABOR.  267 

now  it  must  rotate  through  three-eighths.  Moreover,  it  sometimes 
happens  that  the  shoulders  do  not  rotate  at  all,  or  only  partially,  and 
hence  there  results  greater  or  less  torsion  of  the  neck,  this  torsion  being 
proved  by  the  movement  of  restitution  immediately  following  the 
delivery  of  the  head. 

It  is  natural  to  ask  why  the  occiput  when  in  this  position,  so  near 
the  sacral  cavity,  does  not,  as  the  forehead  did,  rotate,  when  in  a  some- 
what similar  location,  into  that  cavity,  instead  of  by  a  much  longer 
course  seek  the  pubic  arch.  Dr.  Hodge's  answer  was  that  the  promon- 
tory of  the  sacrum  determines  the  whole  head  toward  the  anterior  part 
of  the  pelvis,  and  that  when  the  point  of  the  occiput  strikes  upon  the 
spinous  process  of  the  ischium  rotation  upon  the  right  anterior  inclined 
plane  necessarily  occurs,  but  if  the  point  of  the  occiput  strikes  posteri- 
orly to  this  process,  rotation  into  the  hollow  of  the  sacrum  follows. 

But  the  most  satisfactory  reply  to  the  question  as  to  the  anterior  ro- 
tation of  the  occiput,  and  the  posterior  rotation  of  the  sinciput,  is,  as 
stated  by  Dr.  Ritchie,  that  in  both  anterior  and  posterior  positions  the 
former  is  lower  than  the  latter  when  resistance  begins  ;  in  occipito- 
anterior  positions  that  resistance  from  the  pelvic  floor  begins  when  the 
occiput  is  level  with  the  pubic  arch,  and  the  forehead  with  the  cavity  of 
the  sacrum,  but  in  occipito-posterior  positions  the  resistance  begins  when 
the  occiput  is  past  the  sacral  cavity,  and  the  forehead  too  high  for  the 
pubic  arch.  There  are  forces  of  resistance  presented  to  a  progressive 
mobile  at  different  levels,  and  consequently  they  cause  it  to  rotate,  the 
most  prominent  or  advanced  part  of  that  mobile  moving  in  the  line  of 
least  resistance. 

In  the  further  consideration  of  this  mechanical  phenomenon  we  must 
bear  in  mind  that  unchangeable  law  which  compels  in  all  vertex  deliv- 
eries, whether  artificial  or  natural,  the  occiput  to  pass  out  first.  "When 
the  flexion  is  perfect,  the  head  and  neck  make,  with  the  upper  part  of 
the  thorax,  according  to  the  comparison  of  Dubois,  a  stiff,  inflexible 
rod.  If  the  occiput  rotates  into  the  pubic  arch,  the  neck  more  than 
measuring  the  length  of  the  pubic  joint  the  occiput  can  pass  out,  and 
extension  of  the  head  occur,  and  thus  the  rod  becomes  flexible,  and  the 
trunk  does  not  enter  the  pelvic  cavity  until  the  head  is  being  delivered. 
But  the  condition  is  very  different  in  an  occipito-posterior  position  ;  the 
neck  is  much  shorter  than  the  lateral  wall  of  the  pelvis  with  which  it 
is  in  relation,  and  hence  the  greatest  diameter  of  the  rod,  the  dorso- 
frontal,  must  enter  the  pelvic  inlet,  so  as  to  be  in  relation  with  its  right 
oblique  diameter.  But  the  descending  back,  curved  and  projecting, 
cannot  rest  upon  the  promontory  of  the  sacrum,  and  hence  there  is  a 
force  of  resistance  which  tends  to  throw  the  presenting  part  from  an 
oblique  to  a  transverse  position.  This  change  is  possible  only  when 
flexion  is  perfect — that  is,  when  the  chin  is  so  firmly  pressed  upon  the 
chest  that  the  head  and  upper  part  of  the  trunk  make  a  unit,  and  thus 
a  movement  communicated  to  the  trunk  also  causes  the  head  to  move. 
Meantime,  on  the  other  side  of  the  pelvis  the  forehead  is  not  adapted 
to  the  pubic  arch,  is  resisted  more  by  the  anterior  than  by  the  lateral 
pelvic  wall ;  thus  the  two  resisting  forces  determine  rotation  of  the 
head  from  an  oblique  to  a  transverse  position,  and  then  the  rotation  is 


268  PHYSIOLOGY  OF  LAS  OR. 

continued  until  the  position  becomes  right  occipito-auterior,  from  which 
the  occiput  finally  turns  into  the  pubic  arch. 

In  rare  cases — probably  once  in  fifty,  Stoltz ;  twice  in  fifty,  Uvedale 
West — the  occiput  fails  to  rotate  anteriorly,  but  turns  to  the  sacral 
cavity,  and  the  head  is  in  an  occipito-sacral  instead  of  an  occipito- 
pubic  position.  If  this  posterior  rotation  occurs,  the  head  descends  in 
the  axis  of  the  pelvis ;  but  the  occiput  is  not  adapted  to  the  concavity 
of  the  sacrum,  nor  the  forehead  to  the  pubic  arch,  so  that  both  in  front 
and  behind  space  is  lost.  The  straight,  rigid  rod  cannot  become  flexi- 
ble until  the  occiput  has  traversed  the  sacral  cavity  and  the  inner  sur- 
face of  the  perineum,  so  as  to  pass  out  over  its  anterior  margin  ;  but 
this  end  is  not  possible  until  the  trunk  has  also  entered  the  pelvic 
cavity,  for  the  longest  diameter  of  the  head  is  less  than  the  distance 
from  the  inlet  to  the  vulval  opening.  When  the  occiput  escapes,  the 
nape  of  the  neck  pivots  on  the  anterior  margin  of  the  perineum,  the 
occiput  passing  backward — extension  occurring  in  like  manner  to  that 
observed  in  an  occipito-anterior  delivery — and  the  anterior  fontanelle, 
the  forehead,  and  the  face  are  successively  delivered,  all  the  diameters 
being  suboccipital,  just  as  in  an  occipito-auterior  delivery. 

After  the  head  is  delivered  it  drops  down,  and  then  follow  in  order 
external  rotation  of  the  head  with  internal  rotation  of  the  body,  and 
delivery  of  the  body.  It  is  plain  that  the  labor  is  slower  in  an  occipito- 
posterior  delivery,  not  only  from  the  great  distance  the  occiput  must 
pass  before  it  can  escape  from  the  vulval  opening,  but  also  from  the 
difficulties  in  that  passage ;  the  suffering  of  the  woman  is  greater,  and 
there  is  more  danger  that  the  perineum  will  be  torn.  The  child  is  born 
alive  if  it  is  not  large  and  the  pelvis  is  normal ;  but  if  the  latter  be 
small,  or  the  former  large,  stillbirth  is  common. 

In  very  rare  cases,  if  the  foetal  head  was  small,  conversion  of  a 
vertex  into  a  face  presentation  has  occurred  at  the  inferior  strait,  exten- 
sion taking  place,  so  that  the  chin  instead  of  being  born  last  is  born 
first,  emerging  at  the  pubic  symphysis,  and  the  delivery  of  the  head 
takes  place  by  flexion. 

It  is  unnecessary  to  give  the  diagnosis  and  describe  the  mechanism 
of  labor  in  left  occipito-posterior  position,  for  they  can  be  readily  under- 
stood from  the  explanations  already  made,  substituting  left  for  right  in 
the  description  of  the  diagnosis  and  the  mechanism  of  right  occipito- 
posterior  position. 

In  concluding  this  exposition  of  the  mechanical  phenomena  of  labor 
in  vertex  presentation,  it  must  be  remembered  they  all  concur  to  one 
end,  the  expulsion  of  the  child,  and  therefore  if  one  or  another  is  not 
needed  for  this  end,  it  may  be  absent.  In  the  main  they  are  processes 
of  adaptation,  of  accommodation  of  the  foetal  head  and  body  to  the 
birth-canal,  and  are  the  results  of  a  driving  and  of  resisting  forces, 
hence  varying  as  these  forces  vary.  In  some  cases  the  foetal  head  may 
be  so  small,  or  the  mother's  pelvis  so  large,  that  any  increase  in  the 
head  flexion  is  not  needed  for  descent,  flexion  being  essentially  a  lessen- 
ing of  size  by  placing  a  smaller  head  plane  in  relation  with  a  greater 
pelvic  plane ;  or,  again,  internal  rotation  of  the  head  may  not  occur, 
and  the  head  be  born  in  the  same  oblique  position  which  it  had  upon 


THE  MECHANICAL  PHENOMENA  OF  LABOR.  269 

entering  the  inlet.  These  and  other  variations  in  the  mechanism  of 
labor  are  not,  as  Pajot  well  says,  violations  of  law,  but  occur  because 
some  of  the  factors  which  carry  out  the  law  may  be  absent,  or  others 
have  more  power.  The  phenomena  as  described  always  occur  if  the 
foetal  head,  the  birth-canal,  and  the  driving  force  are  normal.  If,  in  a 
given  case,  two  of  these  phenomena  are  simultaneous,  it  does  not  follow 
that  their  individuality  as  to  causes,  results,  and  diagnosis  is  lost,  and 
that  they  should  be  regarded  as  a  single  event. 

PRESENTATION  OF  THE  FACE.  In  order  that  the  face  may  present, 
the  head  must  be  extended  instead  of  flexed,  the  occiput  bearing  the 
same  relation  to  the  back  that  the  chin  does  to  the  sternum  in  vertex 
presentation. 

FREQUENCY  AND  CAUSES.  Authorities  differ  as  to  the  frequency 
of  presentation  of  the  face  :  1  in  324,  Spiegelberg  ;  1  in  231,  Churchill ; 
1  in  217,  Lachapelle;  1  in  247,  Pinard ;  1  in  175,  Depaul ;  1  in  276, 
Galabin ;  1  in  250  or  300  cases,  Hodge. 

Winckel  has  stated  that  thirty-three  different  causes  have  been  sug- 
gested. One  of  the  most  remarkable  was  that  given  by  Osiander,  viz., 
that  the  foetus  inherited  a  disposition  from  its  parents  to  carry  the  head 
back.  Hodge1  regarded  as  the  best  hypothesis  that  such  presentation 
resulted  from  the  spontaneous  movements  of  the  child,  the  head  being 
fixed  in  this  unusual  posture  by  contractions  of  the  uterus.  Hecker 
regarded  dolicocephalia  as  a  cause.  According  to  him,  the  greater  pro- 
jection of  the  occiput  in  the  dolicocephalic  increased  the  length  of  the 
posterior  arm  of  the  head  lever,  so  that  when  uterine  contractions 
occurred  it  ascended,  while  the  frontal  arm  descended.  The  answer 
generally  made  by  obstetricians  to  this  explanation  is  that  dolicoce- 
phalia is  a  consequence  of  the  delivery  in  a  face  presentation,  not  the 
cause  of  such  presentation,  and  that  it  disappears  a  few  days  after  birth  ; 
further,  even  if  this  condition  be  present,  the  increase  in  the  length  of 
the  occipital  is  never  so  great  as  to  make  it  longer  than  the  frontal  arm. 
Spiegelberg  met  with  a  case  of  face  presentation  in  a  foetus  having  hydro- 
thorax.  Other  instances  are  mentioned  in  which  tumors  of  the  neck 
were  the  cause.  But  apart  from  these  special  causes,  the  general  ones 
are  uterine  obliquity,  pelvic  narrowing,  and  unusual  size  of  the  child. 
The  presentation  occurs  more  frequently  in  multipart  than  in  primi- 

1  Dr.  Meigs  said  "  that  dead  and  half-putrid  children,  in  whose  tissues  there  is  scarcely  any 
resiliency  or  resisting  power  left,  are  not  so  unapt  to  come  face  foremost  as  living  children,  in 
whom  departure  of  the  chin  from  the  breast  occasions  such  a  great  extension  of  the  head  as  to  be 
painful,  whence  the  living  child  instinctively  opposes  the  wrong  tendency,  by  acting  with  all  its 
strength  to  get  the  chin  back,  or  the  head  flexed  again."  The  statement  by  Dr.  Meigs,  and  also 
that  by  Dr.  Hodge,  suggest  a  voluntary  movement  of  the  foetal  head  in  the  one  case  causing  and 
in  the  other  preventing  presentation  of  the  face,  that  is  not  unquestionable.  Sir  Thomas  Browne, 
whose  Religio  Medici  all  doctors  read,  among  his  many  other  literary  works  wrote  a  supposed 
dialogue  between  twins  in  the  uterus,  which  unfortunately  has  been  lost.  Imagining  a  conversa- 
tion under  such  circumstances  is,  of  course,  a  very  wide  step  beyond,  but  is  in  the  same  direction 
as  the  voluntary  movements  that  have  been  suggested.  Those  who  have  observed  how  utterly 
powerless  the  newborn  are  to  move  the  head  in  any  direction,  and  that  it  falls  inert,  according  to 
gravitation  will  hardly  admit  that  the  foetus  can,  against  the  force  of  gravitation,  raise  the  head  a 
single  inch  from  the  chest,  or  that  when  it  is  removed  from  the  chest  by  external  causes  that  the 
foetus,  though  "  acting  with  all  its  strength,"  can  replace  it  if  the  slightest  force  opposes. 

Winckel  indorses  the  criticism  of  the  opinion  of  Drs.  Hodge  and  Meigs  I  have  made.  In  Preyer's 
very  interesting  volume  upon  the  Sord  of  tlie  Infant  the  following  statement  is  made  upon  the 
authority  of  Dremme.  giving  additional  confirmation  :  In  150  children  the  head  may  be  held  in 
equilibrium  if  the  infants  are  very  vigorous  toward  the  end  of  the  third,  or  in  the  first  half  of  the 
fourth  month  ;  in  infants  of  medium  force  this  is  not  seen  until  the  second  half  of  the  fourth 
month,  and  finally,  in  infants  less  vigorous,  somewhat  below  the  normal  in  nutrition,  not  until 
the  fifth  or  the  beginning  of  the  sixth  month. 


270  PHYSIOLOG  Y  OF  LAB  OR. 

parae,  the  proportion  being,  according  to  Kleinwiichter,  1  of  the  former 
to  2.23  of  the  latter.  The  presentation  may  be  primary  or  secondary ; 
the  latter  is  much  the  more  frequent.  The  duration  of  labor  is  in 
primipane  34  hours,  and  in  multipart  15  hours.  The  ordinary  foetal 
mortality  in  vertex  presentation  is  5  per  cent.,  but  in  face  presentation 
15  per  cent.1  Premature  rupture  of  the  bag  of  waters,  prolapse  of  the 
umbilical  cord,  and  tearing  of  the  perineum,  are  among  the  accidents 
liable  to  occur  in  face  presentations. 

MECHANISM.  As  in  presentation  of  the  vertex  the  occiput  was 
selected  as  the  point  of  reference,  so  in  presentation  of  the  face  the 
forehead,  following  the  example  of  Depaul,  will  be  chosen.  Most 
obstetricians  select  the  chin,  naming  the  different  positions  of  the  pre- 
senting part  mento-anterior  and  mento-posterior,  right  or  left,  according 
to  the  side  of  the  pelvis  in  which  the  chin  is  placed.  But  let  the  student 
imagine  a  case  of  vertex  presentation  with  the  occiput  at  the  left  ilio- 
pectineal  eminence,  and  then,  while  the  foetus  is  unchanged  in  its  gen- 
eral position,  let  the  head  be  extended  instead  of  flexed,  and  it  is  seen 
that  the  forehead  at  once  takes  the  position  which  the  occiput  occupied  ; 
and  this  position  is  the  most  frequent  in  presentation  of  the  face. 
Further,  in  many  cases,  if  not  in  the  majority,  presentation  of  the  face 
is  a  deviated  vertex  presentation,  and  such  deviation  can  be  better 
understood  with  the  nomenclature  proposed.  The  various  positions  in 
presentation  of  the  face  will  therefore  be  called  right  or  left  fronto- 
anterior  and  fronto-posterior. 

DIAGNOSIS.  Pinard 2  states  that  examination  of  the  pelvis  enables 
us  to  recognize  the  presence  of  a  large  tumor  at,  above,  or  below  the 
inlet,  according  to  the  period  of  labor  at  which  the  examination  is 
made.  Moreover,  this  tumor  appears  to  occupy  but  one  side,  and  is 
wanting  at  the  other.  Let  the  hand  be  now  at  once  placed  upon  the 
fundus  of  the  uterus,  or  both  may  be  first  put  upon  the  sides  of  the 
uterus  until  the  fundus  is  reached,  and  then  one  of  them  applied  to  it, 
and  we  find,  usually  upon  the  same  side  at  which  the  lower  tumor  was 
prominent,  the  pelvis,  that  may  be  recognized  by  its  peculiar  characters. 
In  order  to  follow  and  appreciate  the  resisting  plane,  it  is  indispensable3 
to  depress  slowly  and  deeply  the  abdominal  wall,  for  this  surface  seems 
to  bury  itself  in  the  abdominal  cavity,  while  the  superficial  parts  are 
readily  felt.  This  is  caused  by  the  bending  of  the  foetus  upon  its  dorsal 
plane.  In  operating  properly  one  of  the  lateral  planes  can  be  examined, 
and  it  is  readily  ascertained  that  the  portion  of  the  cephalic  sphere  most 
accessible  is  in  relation  with  the  back.  Moreover,  between  the  back  and 
the  head  there  is,  especially  early  in  the  labor,  a  deep  depression  into 
which  the  fingers  sometimes  readily  enter.  According  to  Budin,4  one 
can,  in  some  cases,  recognize  on  the  side  opposite  to  the  accessible  tumor 
a  clearly  marked  projection  having  the  form  of  a  horseshoe ;  it  is  formed 
by  the  inferior  maxillary  and  the  chin. 

Charpentier  regards  the  diagnosis  by  palpation  alone  as  exceedingly 
difficult,  stating  that  special  conditions  must  be  present,  relaxation  and 
thinness  of  the  abdominal  walls,  and  a  non-irritable  condition  of  the 

1  Kormann,  quoted  by  KleimvSchtef.  2  Abdominal  palpation. 

3  Pinard,  op.  cit.  *  Op.  cit. 


THE  MECHANICAL  PHENOMENA  OF  LABOR.  271 

uterus,  in  order  thereby  to  make  such  a  diagnosis,  but  it  can  be  made 
by  combining  auscultation  with  palpation.  The  foetus  occupies  a  higher 
position  than  in  vertex  presentation,  so  that  the  maximum  of  the  in- 
tensity of  the  heart-sounds  is  heard  at,  instead  of  below,  the  transverse 
line  (Fig.  105) ;  further,  in  consequence  of  the  head  being  turned  toward 
the  back,  the  latter  is  removed  from  contact  with  the  uterine  wall,  so 
that  the  sounds  are  heard  better  through  the  anterior  wall  of  the  chest ; 
hence  while  the  back  is  felt,  for  example,  on  the  left  side  of  the  uterus, 
the  heart-sounds  are  heard  most  distinctly  upon  the  right  side.  This 
want  of  harmony  between  the  results  obtained  by  palpation  and  by 
auscultation  leads  to  the  diagnosis  of  a  face  presentation,  for  palpation 
would  point  to  the  conclusion  that  there  was  a  vertex  presentation,  but 
auscultation,  both  by  the  fact  that  the  sounds  are  heard  higher  up  than 
in  such  a  presentation,  and  on  the  opposite  side  to  that  upon  which  the 
back  is  found,  justifies  at  least  the  suspicion  that  the  face  presents.1 

After  labor  has  begun,  digital  examination  brings  conclusive  proof 
of  the  presentation.  There  will  be  found  upon  one  side  of  the  pelvis 
a  round,  hard  part,  divided  in  the  median  line  by  the  beginning  of  the 
sagittal  suture,  and  bounded  by  the  fronto-parietal  suture,  and  in  the 
median  line  by  the  bregma ;  while  upon  the  other  side  of  the  pelvis 
there  is  felt  a  smaller,  softer,  and  irregular  surface ;  this  surface  imme- 
diately next  to  the  frontal  bone  offers  two  soft,  round,  small  tumors, 
the  globes  of  the  eyes;  there  is  a  depressed  surface  between  them, 
then  from  it  there  rises  a  projecting  part  which  ends  in  two  open- 
ings, the  nares ;  below  the  nares  and  transverse  to  them  is  the  mouth, 
into  which  the  finger  may  be  introduced,  and  in  some  cases  this  intro- 
duction is  followed  by  efforts  on  the  part  of  the  infant  to  suck ;  below 
the  mouth  the  chin  is  found,  the  direction  in  which  it  points  being 
plainly  indicated  by  the  opening  of  the  nares.2 

If  the  labor  has  been  in  progress  for  some  time,  the  membranes 
having  been  ruptured,  the  face  becomes  greatly  swelled  and  its  form 
changed ;  one  feature,  however,  remains  comparatively  unaltered,  the 
nose ;  by  this  the  diagnosis  of  the  presentation  can  usually  be  made, 
and  when  the  nose  is  recognized  the  position  is  known,  for  the  former 
points  in  a  direction  opposite  to,  the  forehead.  The  mouth  should  not 
be  confounded  with  the  anus,  for  the  projection  caused  by  the  point  of 
the  coccyx  is  always  readily  found  near  the  latter. 
-f  LEFT  FEONTO-ANTERIOR  POSITION.  This  is  the  most  frequent 
position.  The  back  is  found  by  palpation  upon  the  left  anterior  side 
of  the  uterus;  the  foetal  heart-sounds  are  heard  most  distinctly  upon 
the  right  side.  Upon  vaginal  examination  the  nose  is  found  pointing 
toward  the  right  sacro- iliac  joint,  and  hence  the  forehead  must  be  at 
the  left  ilio-pectineal  eminence. 

1.  The  first  of  the  mechanical  phenomena  of  labor  is  increase  of 
extension,  the  occiput  turned  against  the  back ;  complete  extension  in 
presentation  of  the  face  corresponds  with  complete  flexion  in  presenta- 
tion of  the  vertex.  Its  cause  is  the  driving  force  met  by  the  unequal 

1  Fischel  states  the  heart's  action  maybe  felt  in  face  or  brow  presentation,  when  the  anterior 
part  of  the  chest  lies  in  contact  with  the  uterine  wall,  after  rupture  of  membranes. 

2  Winckel  states  that  in  the  diagnosis  of  this  presentation  chief  reliance  should  be  made  upon 
recognizing  the  mouth  and  tongue. 


272  PHYSIOLOGY  OF  LABOR. 

resistance  of  the  two  arms  of  the  face  lever.  In  Fig.  119,  A  F,  being 
the  long  arm,  necessarily  offers  more  resistance  than  A  M,  the  short 
arm  ;  hence  the  chin  descends  and  the  forehead  ascends.  Further,  the 
head  being  already  partially  extended,  prepares  the  way  for  complete 
extension.  The  result  of  perfect  extension  is  :  There  is  a  lessened  area 
of  the  head  circumference  brought  in  relation  with  the  pelvic  area,  for, 
prior  to  complete  extension,  that  circumference  corresponded  with  a 
diameter  passing  from  the  chin  to  the  bregma,  the  mento-bregmatic 
diameter,  while  now  the  diameter  whose  circumference  occupies  the  pel- 
vic area  is  the  frouto-mental.  There  is  no  loss  of  force,  at  least  after 
the  waters  have  been  evacuated  and  direct  pressure  upon  the  breech  per- 
mitted, for  the  foetus  is  no  longer  "  a  vacillating  rod  "  in  consequence 
of  the  mobility  at  the  cervical  vertebrae,  but  compacted  together  by  the 
occiput  being  fixed  upon  the  back.  Complete  extension  is  recognized 
by  the  recession  of  the  forehead,  and  by  the  advance  of  the  chin  toward 
the  centre  of  the  pelvic  cavity. 

FIG.  118. 


FRONTO-ANTERIOR  POSITION  IN  PRESENTATION  OF  FACE. 

2.  Descent.     This  does  not  need  to  be  defined  nor  its  cause  explained. 

3.  Rotation.     It  is  essential,  in  order  that  delivery  can  take  place,  in 
the  ordinary  relations  of  the  size  of  the  pelvis  and  that  of  the  foetus, 
that  the  chin  rotate  anteriorly;  that  must  escape  first  before  any  flexion 
of  the  foetal  rod  is  possible.     The  descent  is  at  an  end  as  soon  as  the 
length  of  the  child's  head  has  been  measured  upon  the  pelvic  wall,  for 
then  the  chest  tends  to  enter  the  pelvis,  but  the  latter  cannot  accommo- 
date both  head  and  trunk.     The  length  of  the  pelvic  lateral  wall  is 
three  inches  and  a  half,  between  nine  and  ten  centimetres,  while  the 
anterior  wall  is  only  one  inch. and  a  half  long  (four  centimetres),  a  dis- 
tance readily  measured  by  the  neck.     Ordinarily,  therefore,  it  follows 


THE  .MECHANICAL  PHENOMENA  OF  LABOR. 
Fre.  119. 


273 


M 


ATTITUDE  OF  THE  HEAD  IN  PRESENTATION  OF  THE  FACE. 

that  rotation  of  the  forehead  into  the  sacral  cavity,  and  of  the  chin  into 
the  pubic  arch,  occurs  before  the  face  reaches  the  pelvic  floor. 


ROTATION  FORWARD  OF  THE  CHIN. 
18 


274  PHYSIOLOGY  OF  LABOR. 

Dr.  Hodge,  however,  with  Velpeau  and  Chailly,  held  that  in  many  instances 
"the  chin  will  pass  below  the  sacro-sciatic  ligament,  and  will  often  distend  the 
perineum  to  a  great  degree."  He  justified  this  opinion  by  the  following  consid- 
erations :  First,  the  length  of  the  neck  is  to  be  measured,  not  from  the  hyoid  bone, 
but  from  the  chin  to  the  chest.  When  the  head  is  in  a  state  of  extension  we 
would  have  at  least  three  inches  and  a  half,  and  if  the  neck  be  elongated,  probably 
four  inches  from  the  chin  to  the  sternum.  Second,  the  neck  can  be  elongated  to 
a  considerable  degree  in  these  cases  of  great  extension. 

If  these  views  were  correct,  we  would  probably  have  delivery  of  the 
foetus  in  face  presentation,  without  anterior  rotation  of  the  chin,  as  a 
frequent  occurrence.  Admitting,  too,  the  great  elongation  of  the  neck 
claimed  by  Dr.  Hodge,  which,  however,  is  of  the  anterior  portion,  this 
does  not  obviate  the  difficulty  arising  from  both  the  head  and  chest 
occupying  the  pelvic  cavity  at  the  same  time. 

FIG.  121. 


PASSAGE  OF  THE  HEAD  THROUGH  THE  EXTERNAL  PARTS  IN  FACE  PRESENTATION. 
The  bead  is  becoming  flexed  and  sweeping  over  the  perineum. 

The  reasons  for  posterior  rotation  of  the  forehead  are  that  it  offers  a 
more  extensive  surface,  and  the  frontal  arm  of  the  face-lever  is  the 
longer,  and  hence  meets  with  greater  resistance ;  it  finds  more  room  and 
can  be  better  accommodated  behind  than  in  front.  With  the  correspond- 
ing rotation  of  the  chin  into  the  pubic  arch  the  mental  end  of  the  face- 
lever  is  free;  it  no  longer  meets  resistance  from  the  bony  wall  of  the 
pelvis,  and  the  head  is  no  longer  pressed  against  the  back,  but  can  be 
delivered,  thus  giving  room  in  the  pelvic  cavity  for  the  descent  of  the 
body. 

4.  Delivery  of  the  head  by  flexion.  The  chin  escapes,  and  thus  the 
occipito-mental  diameter  is  free  to  rotate  partially.  The  head  is,  as  it 
were,  rolled  out  of  the  vulval  opening,  flexion  occurring,  the  throat 
applied  to  the  summit  of  the  pubic  arch,  the  chin  ascending  over  the 
pubic  joint  until  the  occipital  end  of  the  occipito-mental  diameter 


THE  MECHANICAL  PHENOMENA  OF  LABOR.  275 

escapes  over  the  perineum,  when  the  head  drops  down  toward  the  anus 
as  it  did  after  vertex  delivery.  Here  again  we  have  illustrated  the  fact 
that  when  one  end  of  the  long  diameter  of  the  foetal  head  enters  the 
pelvis,  that  end  must  pass  out  of  it  first. 

5.  External  rotation  of  the  head  with  internal  rotation  of  the 
shoulders.  The  conditions  are  the  same  as  in  vertex  delivery,  and  the 
causes  of  the  rotations  and  the  consequences  are  identical.  The  fore- 
head, or  the  chin,  always  turns  toward  that  thigh  corresponding  with 
the  side  of  the  pelvis  which  it  occupied  ;  thus,  if  the  forehead  was  in 
relation  with  the  left  side  of  the  pelvis,  it  turns  toward  the  left  thigh. 

6.  Delivery  of  the  body.  This  is  the  same  as  in  presentation  of  the 
vertex. 

ANOMALIES  OF  MECHANISM  IN  FACE  PRESENTATIONS.  In  some 
cases  there  may  be,  in  consequence  of  imperfect  extension,  presentation 
of  the  forehead.  But  this  rarely  persists,  for  either  flexion  occurs  and 
the  presentation  becomes  that  of  the  vertex,  or,  and  this  is  the  more 
frequent,  extension  is  completed  and  there  is  simply  a  face  presentation. 
Sometimes,  however,  the  forehead  remains  the  presenting  part,  and  is 
delivered  first.  The  anomalies  of  the  third  time,  rotation  of  the  chin 
in  front,  are  the  most  important.  Not  only  may  this  rotation  fail,  but 
posterior  rotation  by  which  the  chin  turns  to  the  sacral  cavity  may 
occur.  Apparently  spontaneous  expulsion  is  impossible.  Velpeau 
thought  that  flexion  of  the  head  might  then  take  place  by  which  the 
vertex  would  be  substituted  for  the  face.  But  this  is  impossible  after 
the  head  enters  the  pelvic  cavity  if  the  foetus  and  pelvis  are  of  usual 
size.  Cazeaux  suggested  that  the  soft  parts  might  be  depressed  at  the 
great  sciatic  foramen,  "  a  depression  permitting  the  chin  to  escape  from 
the  bony  canal,"  so  that  the  long  diameter  of  the  foetal  head  might 
turn,  and  presentation  of  the  vertex  be  substituted  for  that  of  the  face. 
Another  explanation  was  proposed  by  Dubois  from  two  cases  observed 
by  him.  The  chin  was  behind  and  to  the  right,  descent  to  the  inferior 
strait  occurred,  and  after  the  chin  passed  below  the  great  sciatic  liga- 
ment it  depressed  the  soft  parts  so  that  space  was  gained  to  permit 
flexion  of  the  head  at  the  expense  of  the  elasticity  of  the  pelvic  floor, 
and  labor  ended  with  presentation  of  the  vertex. 

Pajot  remarks  that  in  directly  posterior  positions,  which  are  so  rare 
that  he  has  never  seen  one,  that  Chailly  has  suggested  an  analogous 
mechanism  theoretically  probable,  permitting  spontaneous  delivery. 
The  chin  having  reached  the  point  of  the  coccyx,  depresses  the  pelvic 
floor  so  that  rotation  of  the  occipito-mental  diameter  can  occur,  and  the 
occiput  is  disengaged  under  the  pubic  arch.  But  whatever  opinion  may 
be  suggested  as  to  the  termination  of  the  labor  in  mento-posterior  posi- 
tion,1 practice  demonstrates  that  they  very  rarely  persist,  and,  moreover, 
when  rotation  of  the  chin  does  not  occur,  difficulties  ordinarily  arise 
requiring  the  intervention  of  art. 

PLASTIC  CHANGES.  The  form  of  the  head  is  dolicocephalic ;  the 
longitudinal  diameters  are  increased,  the  vertical  and  transverse 
diminished. 

The  face  is  greatly  swelled  and  discolored  ;  the  eyelids  likewise,  and 

i  Pajot. 


276  PHYSIOLOGY  OF  LABOR. 

it  is  impossible  for  the  infant  to  open  them ;  in  some  cases  the  lips  are 
so  greatly  swollen  that  the  infant  cannot  nurse ;  very  often  subcon- 
junctival  hemorrhage  is  present.1  The  caput  succedaneum  occupies  the 
inferior  part  of  the  malar  region  and  the  side  of  the  mouth  in  fron to- 
posterior  positions;  on  the  contrary,  it  is  situated  upon  the  superior 
part  of  the  malar  region  and  even  upon  the  eye  in  frouto-auterior  posi- 
tions. Mauriceau2  has  given  a  very  graphic  description  of  the  appear- 
ance of  a  child's  face  after  birth  with  facial  presentation. 

Right  fronto-posterior  position  is  the  reverse  of  left  frou to-anterior ; 
and  just  as  the  former  might  be  considered  a  deviation  of  the  most  fre- 
quent position  of  vertex  presentation,  extension  taking  the  place  of 
flexion,  so  that  instead  of  the  occiput  the  forehead  is  at  the  left  ilio- 
pectiueal  eminence,  so,  imagining  first  the  next  most  frequent  position 
of  vertex  presentation,  right  occipito-posterior,  we  may  suppose  a  devi- 
ation to  result  from  extension  taking  the  place  of  flexion,  so  that  the 
forehead  instead  of  the  occiput  is  placed  at  the  right  sacro-iliac  joint. 
The  mechanism  of  labor  is  the  same  as  has  been  described.  1.  Com- 
pletion of  extension.  2.  Descent.  3.  Rotation.  As  the  chin  is  so 
much  nearer  the  pubic  arch  in  this  position  than  in  left  fronto-anterior, 
this  process  occupies  much  less  time.  4.  Delivery  of  the  head  by 
flexion.  5.  External  rotation  of  the  head  with  internal  rotation  of  the 
shoulders.  6.  Expulsion  of  the  body.  It  is  only  necessary  to  mention 
the  names  of  the  two  other  positions  of  face  presentation,  right  fronto- 
anterior  and  left  fronto-posterior,  for  a  description  of  the  mechanism  of 
labor  in  these  positions  would  be  essentially  a  repetition. 

PELVIC  PRESENTATIONS.  Presentations  of  the  pelvis  are  next  in 
frequency  to  those  of  the  vertex,  and  occur  once  in  twenty  to  thirty 
cases  in  single  pregnancies,  but  more  frequently  in  twin  pregnancies. 
Excluding  cases  of  premature  labor,  pelvic  presentations  occur,  accord- 
ing to  Pinard,  once  in  sixty-two. 

VARIETIES  AND  CAUSES.  Usually  the  upper  and  lower  limbs 
occupy  the  same  position  with  reference  to  the  trunk  that  they  do  in 
vertex  or  in  face  presentations.  In  some  cases,  however,  not  only  are 
the  thighs  flexed  upon  the  abdomen,  but  the  legs  extended  over  the 
chest.  The  knees  may  descend  first,  though,  according  to  Spiegelberg, 
such  presentation  is  never  primitive,  one  or  both  feet  may  descend,  but 
these  various  modifications  do  not  affect  the  essential  mechanism  of 
labor.  Whether  knees,  feet,  thighs,  or  pelvis  present,  all  are  included 

1  A  remarkable  case  of  fatal  hemorrhage  from  the  conjunctiva  in  an  infant  born  with  face  pres- 
entation occurred,  March,  1890,  during  one  of  my  terms  of  service  at  the  Philadelphia  Hospital.  Dr. 
Frank  R.  Keefer,  maternity  resident,  had  charge  of  the  mother  in  her  labor,  and  has  given  me  a 
full  report  of  the  case,  which  I  hope  to  publish  with  some  comments  at  an  early  day.    Suffice  it 
now  to  say  that  the  child  was  delivered  spontaneously  after  a  not  unusually  long  labor ;  it  seemed 
quite  well,  weighed  eight  pounds,  and  had  only  the  usual  appearance  of  a  child  born  presenting 
the  face.    The  bleeding  began  twelve  hours  after  birth  ;  the  oozing  was  first  from  the  conjunctiva 
of  the  right  upper  lid,  and  after  a  few  hours  from  the  palpebral  conjunctiva  of  the  left  eye.    In 
spite  of  various  local  means,  some  of  which  temporarily  arrested  the  bleeding,  the  child  perished 
of  hemorrhage  a  little  more  than  twelve  hours  after  the  first  oozing  appeared. 

2  In  Mauriceau's  Diseases  of  Women  with  Child,  etc.,  translated  by  Hugh  Chamberlen,  and  pub- 
lished in  1727,  the  great  French  obstetrician  tells  of  a  child  being  born  face  first,  that  "  came  with 
the  face  so  black  and  misshapen  as  soon  as  it  was  born,  as  usually  in  such  cases,  that  it  looked  like 
a  blackamoor.  As  soon  as  the  mother  saw  it  she  told  me  that  she  always  feared  her  child  would  be 
so  monstrous,  because  when  she  was  young  with  child  she  fixed  her  looks  very  much  upon  a  black- 
amoor belonging  to  the  Duke  of  Guise,  who  always  kept  several  of  them.    Wherefore  she  wished 
that,  or  at  least  cared  not  though  it  died,  rather  than  to  behold  a  child  so  disfigured  as  it  then  ap- 
peared.   But  she  soon  changed  her  mind  when  I  satisfied  her  that  this  blackness  was  only  because 
it  came  faceling,  and  that  assuredly  in  three  or  four  days  it  would  wear  away." 


THE  MECHANICAL  PHENOMENA  OF  LABOR.  277 

under  the  general  name  of  pelvic  presentations.  Multiparity,  prema- 
ture labor,  polyhydramuios,  plural  pregnancy,  the  foetus  being  dead,  or 
of  small  size,  or  hydrocephalic,  pelvic  narrowing,  uterine  tumors,  and 
placenta  praevia  are  the  chief  causes  of  pelvic  presentations.  In  regard 
to  the  last,  it  is  probable  that  it  is  not  the  fact  of  the  placenta  being 
prsevia  which  causes  pelvic  presentation,  but  they  both  result  from  a 
common  cause,  the  condition  of  the  uterus. 


FIG.  122. 


PELVIC  PRESENTATION.    RIGHT  SACKO-ANTERIOR  POSITION. 

DIAGNOSIS.  Before  labor  the  pelvic  cavity  will  be  found  empty,  aud 
the  lower  portion  of  the  foetal  ovoid  is  partly  in  one  or  the  other  iliac 
fossa  usually,  and  partly  over  the  inlet ;  there  will  be  found  adjacent  to 
this  portion,  except  when  the  legs  are  extended  over  the  chest,  small 
movable  parts ;  the  head  is  in  the  proper  portion  of  the  uterus,  and  in 
the  majority  of  cases  at  the  right  side,  though  in  the  illustration  it  is 
represented  in  the  left,  aud  cephalic  ballottemeut  may  be  made.  Upon 
auscultation  the  maximum  of  intensity  of  the  heart-sounds  will  be 
found  above  the  horizontal  line  at  Fig.  105. 

Early  in  the  labor  before  the  presenting  part  has  descended  into  the 
pelvic  cavity,  and  the  foetal  sac  is  entire,  it  will  be  difficult  or  impossi- 
ble to  make  a  diagnosis  by  vaginal  examination.  The  bag  of  waters 
is  large,  and  is  sometimes  described  as  "  pudding-shaped  ;"  such  size 
and  shape,  and  difficulty  in  reaching  the  presenting  part,  render  it 
probable  the  presentation  is  pelvic.  After  the  rupture  of  the  sac  and 
the  descent  of  the  pelvis,  there  usually  is  no  difficulty  in  making  a 
diagnosis.  The  finger  touches  a  round  object,  but  it  is  softer,  less  uni- 
form in  shape  than  the  head,  aud  has  neither  sutures  nor  fontauelles, 
nor  the  feeling  of  the  scalp,  wrinkled  aud  covered  with  hair.  The 
separation  between  the  buttocks,  the  coccyx,  the  sacral  crest,  the  anus, 


278 


PHYSIOLOGY  OF  LABOR. 


and  the  sexual  organs  may  be  recognized ;  if  the  child  be  alive,  the  anus 
contracting  resists  the  effort  to  introduce  the  finger,  and  the  latter  upon 
withdrawal  will  be  covered  with  meconiura.  If  the  feet  are  pressed 
against  the  thighs,  so  that  one  of  them  may  be  touched  by  the  finger, 
the  diagnosis  becomes  easier.  If  the  coccyx  be  felt,  the  position  is  at 
once  known,  for  its  point  is  always  directed  toward  the  anterior 
plane  of  the  foetus.  If  a  foot  only  is  accessible  to  touch,  it  is  dis- 
tinguished from  the  hand  by  being  at  a  right  angle  to  the  leg,  by  its 
being  thicker  upon  one  side  than  upon  the  other,  by  the  toes  being 
placed  in  the  same  line,  by  the  impossibility  of  separating  the  great  toe 

FIG.  123. 


DIAGNOSIS  OF  PELVIC  PRESENTATION  BY  PALPATION. 


from  the  second,  and  bringing  the  former  in  opposition  to  the  other 
toes,  as  the  thumb  can  be  separated  from  the  index  finger,  and  brought 
in  opposition  to  the  fingers;  the  projection  of  the  os  calcis  is  also  an 
important  mark  by  which  the  foot  can  be  distinguished  from  the  hand. 
Presentation  of  a  knee  is  very  rare.  The  knee  is  broader  than  the 
elbow,  and  the  patella  flat,  while  the  olecranon  is  pointed ;  the  thigh 
and  the  leg,  between  which  the  knee  is  felt,  are  thicker  than  the  arm 
and  the  forearm.  If  there  still  be  uncertainty  in  the  diagnosis,  the 
member  may  be  extended,  and  then  the  foot  will  be  recognized.  When 
the  leg  is  extended  the  toes  point  to  the  anterior  plane  of  the  foetus ; 
but  if  the  leg  be  flexed  upon  the  extended  thigh,  the  toes  point  to  the 
posterior  plane. 


THE  MECHANICAL  PHENOMENA  OF  LABOR. 


FIG.  124. 


279 


PELVIC  PRESENTATION. 
A,  Place  where  sounds  of  foetal  heart  are  heard  most  distinctly  in  left  sacro-anterior  position. 


MECHANISM  OF  LABOR.  The  positions  are  named  according  as  the 
sacrum  of  the  foetus  is  anterior  or  posterior,  in  the  left  or  right  side  of 
the  mother's  pelvis ;  thus  we  have  four  positions  for  pelvic  presenta- 
tion :  1,  left  sacro-anterior,  the  sacrum  being  at  the  left  ilio-pectineal 
eminence,  the  most  frequent  position  ;  2,  right  sacro-posterior,  the  sa- 
crum being  at  the  right  sacro-iliac  joint ;  3,  right  sacro-auterior ;  and  4, 
right  sacro-posterior.  Here,  too,  there  are  six  stages,  times,  or  processes 
in  the  mechanism  of  labor,  as  have  been  given  in  presentation  of  the 
vertex  and  in  presentation  of  the  face. 

1.  Compression  of  the  presenting  part.     Just  as  a  scattered  crowd  is 
brought  into  a  compact  mass  in  order  to  go  from  a  ferry-boat  to  the 
landing-wharf,  so  the  presenting  part  is  compacted  together,  reduced  to 
the  smallest  dimensions,  in  order  that  it  cau  be  transmitted  through  the 
birth-canal.      It  is  a  process  of  lessening,  of  adaptation  of  the  pas- 
senger to  the  passage.     In  presentation  of  the  vertex  this  process  was 
by  completion  of  flexion,  and  in  presentation  of  the  face  by  completion 
of  extension ;  in  all  the  changes  there  is  a  lessening  of  the  presenting 
part,  and  the  means  by  which  the  changes  are  effected  are  the  same 
driving  and  resisting  forces,  and  in  all  the  purpose  of  the  change  is 
the  same,  the  foetal  region  is  reduced  to  a  form  and  size  corresponding 
with  the  canal  through  which  it  must  pass. 

2.  Descent.     This  needs  no  explanation. 

3.  Rotation  of  the  anterior  hip  into  the  pubic  arch,  so  that  the  bis- 
trochanteric  diameter  is  placed  in  relation  with  the  antero-posterior 


280 


PHYSIOLOGY  OF  LABOR. 


diameter  of  the  outlet ;  this  rotation  includes  the  trunk  of  the 
child. 

4.  Delivery  of  the  body.  The  anterior  hip  is  at  the  pubic  arch,  and 
the  posterior  at  the  other  end  of  the  coccy pubic  diameter. 

The  pubic  thigh  remains  fixed,  forced  against  the  subpubic  ligament, 
and  makes  the  pivotal  point  upon  which,  by  partial  curvature,  the  hips 
pass  out ;  the  posterior  thigh  sweeps  along  the  periueal  gutter,  and  the 
lower  portion  of  the  body  is  delivered,  greatly  latero-flexed.  The 
anterior  shoulder  now  descends  into  the  pubic  arch,  is  fixed  there,  while 
the  posterior  shoulder  sweeps  over  the  perineum  and  is  delivered  first, 
meantime  the  arms  and  forearms  remaining  closely  applied  to  the  chest. 

FIG.  125. 


EXPULSION  OF  THE  BREECH. 

5.  Internal  rotation  of  the  head  and  external  rotation  of  the  trunk. 
This  movement  is  designed  to  bring  the  occiput  behind  the  pubic  joint 
and  the  face  into  the  sacral  cavity.     It  is  essentially  the  same  as  that 
which  is  observed  in  a  vertex  presentation,  only  it  occurs  last  instead  of 
first.     Its  purpose  is  to  place  the  head  in  the  most  favorable  position  for 
expulsion,  a  suboccipital  being  brought  in  relation  with  the  longest 
diameter  of  the  outlet. 

6.  Delivery  of  the  head.     The  head  is  forced  down,  the  chin  closely 
applied  to  the  chest,  the  nucha  pivots  against  the  pubic  arch,  while  the 
chin  is  born  first,  then  the  face,  forehead,  bregma,  and,  finally,  the 
occiput  emerge,  the  diameters  presented  being,  as  in  head-first  deliveries, 
suboccipital. 

ANOMALIES  IN  THE  MECHANISM.  The  only  one  of  importance  is 
that  which  may  occur  in  the  fifth  time,  arising  from  the  failure  of  the 
occiput  to  rotate  behind  the  pubic  joint,  but  it  rotates  into  the  sacral 
cavity ;  the  back  of  the  child,  instead  of  being  anterior,  is  now  posterior. 
The  mechanism  is  different  according  as  flexion  of  the  head  remains  or 


THE  MECHANICAL  PHENOMENA  OF  LABOR.  281 

as  extension  occurs,  the  chin  resting  upon  the  chest  in  the  one  case,  but 
departing  from  it  in  the  other.  In  the  former  the  nucha  presses  upon 
the  anterior  margin  of  the  perineum,  and  the  head  is  delivered  by  exten- 
sion occurring,  the  chin,  face,  forehead,  bregma,  and  occiput  passing  out 
in  succession,  the  back  of  the  child  being  turned  toward  the  mother's 
back.  But  when  the  chin  departs  from  the  chest  it  is  delayed  above 
the  pubic  joint,  extension  is  completed  so  that  the  occipital  end  of  the 
occipito-mental  diameter  passes  out  first,  then  the  rest  of  the  head, 
delivery  occurring  by  flexion,  the  throat  pivoting  upon  the  pubic  joint; 
the  abdomen  of  the  child  in  the  delivery  comes  toward  the  abdomen  of 
the  mother. 

FIG.  126. 


EXPULSION  OF  THE  SHOULDERS. 


PLASTIC  CHANGES.  The  caput  succedaneum  is  usually  found  upon 
the  anterior  thigh,  but  the  swelling  may  also  involve  the  external  geni- 
tals, which  are  often  greatly  discolored.  The  head  is  remarkable  for  its 
round  appearance ;  this  arises  from  the  fact  that  it  is  pressed  at  all  points 
except  at  the  top. 

MECHANISM  IN  THE  DIFFERENT  POSITIONS.  First.  Left  Sacro- 
anterior:  1.  Compression.  2.  Descent.  3.  Rotation.  It  is  unnecessary 
to  give  all  the  details.  In  this  position  the  back  is  toward  the  mother's 
left  side  anteriorly,  the  sacrum  at  the  left  ilio-pectineal  eminence,  the 
bistrochanteric  diameter  is  in  relation  with  the  left  oblique,  and  the 
sacro-pubic  with  the  right  oblique  of  the  inlet.  The  anterior  hip,  here 
the  left,  rotates  from  the  right  into  the  pubic  arch. 

4.  Delivery  of  the  body.  The  left  hip  is  flexed  at  the  pubic  arch, 
pressing  against  the  subpubic  ligament ;  the  right  hip,  passing  over  the 
sacro-coccygeal  concavity  and  the  perineal  floor,  emerges  at  the  anterior 
perineal  margin,  the  body  of  the  foetus  being  curved  upon  its  lateral 


282  PHYSIOLOGY  OF  LABOR. 

plane.  The  shoulders  descend — the  bisacromial  diameter  has  the  same 
relation  with  the  coccypubic  diameter  that  the  bistrochanteric  had — and 
the  trunk  is  entirely  born. 

5.  Internal  rotation  of  the  head  and  external  rotation  of  the  body. 
The  occiput  turns  from  left  to  right  behind  the  pubic  joint,  the  chin 
firmly  pressed  upon  the  chest. 

6.  Delivery  of  the  head.   This  occurs  by  extension,  the  chin  passing  out 
first,  then  the  rest  of  the  face,  the  forehead,  the  bregma,  and  the  occiput 
— the  back  of  the  foetus  is  directed  toward  the  abdomen  of  the  mother. 

Second.  Right  Sacro-posterior  Position.  In  this  position  the  sacrum 
is  directed  to  the  right  sacro-iliac  joint.  The  right  hip  is  anterior.  The 
only  difference  in  the  mechanism  from  that  observed  in  left  sacro-anterior 
position  is  that  the  right  hip  turns  from  the  right  side  in  front.  The 
mechanism  in  each  of  the  other  positions  can  be  readily  understood 
from  the  descriptions  that  have  been  given. 

PRESENTATION  OF  THE  SHOULDER.  Either  the  right  or  the  left 
shoulder  may  present,  and  for  each  there  are  two  positions,  depending 
upon  the  relation  of  the  back  of  the  fetus  to  the  abdomen  of  the 
mother,  and  hence  known  as  dorso-anterior  and  dorso- posterior.  Pres- 
entations of  the  right  shoulder  are  somewhat  more  frequent  than  those 
of  the  left ;  dorso  anterior  positions  are  at  least  twice  as  frequent  as 
dorso-posterior.  Pinard,  indeed,  states  that  he  never  met,  during  preg- 
nancy, with  shoulder  presentations  unless  occupying  a  dorso-anterior 
position.  Shoulder  presentations  occur  once  in  about  125  labors,  Pinard ; 
6  to  7  in  1000,  Kleinwiichter;  1  in  297  Galabin  gives  as  the  proportion 
found  from  the  statistics  of  Guy's  Hospital  Lying-in  Charity. 

CAUSES  OF  PRESENTATION  OF  SHOULDER.  Smallness  of  the  foetus, 
its  being  dead,  premature  labor,  polyhydramnios,  peculiar  shape  of  the 
womb,  plural  pregnancy,  relaxation  of  uterine  and  of  abdominal  walls, 

FIG.  127. 


TRANSVERSE  PRESENTATION.    DORSO-ANTERIOR.    PRESENTATION  OF  RIGHT  SHOULDER. 


pelvic  narrowing,  and  placenta  praevia  are  given  as  causes.  As  to  the 
last,  the  remark  made  in  regard  to  pelvic  presentations  being  similarly 
caused,  is  here  also  applicable. 

DIAGNOSIS.      1.    Before  labor   begins,   according  to   Depaul,   the 


THE  MECNANICAL  PHENOMENA  OF  LABOR. 


283 


maximum  of  intensity  of  the  foetal  heart-sounds  is  at  the  level  of  the 
line  dividing  the  uterus  in  two  equal  parts,  aud  the  line  of  decrease 
of  this  maximum  is  horizontal,  not  vertical.  This  is  shown  in  the 
illustration,  Fig.  129. 


FIG.  128. 


TRANSVERSE  POSITION.    DORSO-POSTERIOR.    PRESENTATION  OF  RIGHT  SHOULDER. 

By  abdominal  palpation  the  form  of  the  uterus  is  found  very  different 
from  the  usual  shape,  being  increased  transversely ;  but  it  is  a  mistake 
to  suppose,  as  is  represented  in  some  drawings,  that  the  foetus  will  be 
found  lying  with  its  head  in  one,  its  hips  in  the  other  iliac  fossa ;  for 

FIG.  129. 


A,  POINT  OF  MAXIMUM  OF  INTENSITY  OF  SOUNDS  OF  FCETAL  HEART  IN  PRESENTATION 
OF  THE  SHOULDER. 

apart  from  any  other  reason  the  distance  between  the  fossa3  is  much  less 
than  the  length  of  the  foetal  ovoid  at  or  near  term.  The  head  is  usually 
lower  than  the  hips,  for  the  shoulder,  in  most  cases,  is  in  relation  with 
the  pelvic  area.  Then  by  palpation  the  head  is  felt  in  one  iliac  fossa 


284 


PHYSIOLOGY  OF  LABOR. 


while  the  breech  is  found  in  the  opposite  flank,  and  a  resisting  plane 
connects  the  two ;  cephalic  ballottement  is  possible  (Fig.  130).  Vaginal 
examination  is  without  value  prior  to  labor. 

During  labor  auscultation  remains  the  same.  The  head  is  pressed 
nearer  the  inlet,  and  can  be  felt  more  distinctly,  but  ballottemeut  is  now 
impossible.  The  pelvic  extremity  is  brought  nearer  the  fundus  of  the 
uterus,  toward  the  median  line,  and  the  resisting  plane  which  unites  the 
two  ends  of  the  fetal  ovoid  is  also  brought  nearer  the  vertical  line.1 

FIG.  130. 


SHOWING  DIAGNOSIS  OF  SHOULDER  PRESENTATION  BY  PALPATION. 

Depaul  has  dwelt  upon  the  "  peculiar  physiognomy  "  of  labor  in  case 
of  shoulder  presentation.  The  uterus  does  not  contract  with  the  same 
regularity  that  it  does  in  vertex  presentation ;  very  frequently  quite  a 
long  time  passes  in  which  the  contractions  come,  are  suspended,  and 
then  resume,  without  producing  a  marked  effect;  the  os  scarcely  dilates, 
and  sometimes  twelve,  twenty-four,  forty-eight  hours,  or  even  more 
pass,  without  the  part  engaging  in  the  inlet.  The  bag  of  waters  is 
unusually  large,  and  sometimes  reaches  down  between  the  labia.  If  the 
presenting  part  cannot  be  reached  by  the  two  fingers,  and  auscultation 
and  abdominal  palpation  have  rendered  it  probable  that  the  shoulder 
presents,  it  is  better  to  introduce  the  hand  into  the  vagina  so  that  the 
diagnosis  may  be  made  certain.  The  shoulder  is  round,  and  presents  a 
bony  prominence,  the  acromion.;  but  the  most  characteristic  feature  is  the 
axilla,  with  the  ribs  parallel  to  each  other,  like  the  bars  of  a  gridiron, 

1  Charpentler. 


THE  MECHANICAL  PHENOMENA  OF  LABOR.  285 

called  by  Pajot  the  intercostal  gridiron.  The  cavity  of  the  axilla 
formed  by  the  arm  and  the  wall  of  the  chest  represent  an  angle  opening 
toward  the  hips,  and  its  apex  pointing  toward  the  head ;  and  hence 
when  this  is  recognized  the  side  occupied  by  the  head  is  at  once  known. 
Next,  the  position  of  the  breech  is  to  be  determined,  whether  anterior 
or  posterior ;  this  is  done  by  feeling  the  scapula  or  the  clavicle,  the  for- 
mer corresponding  to  the  posterior,  the  latter  to  the  anterior  plane  of 
the  fetus;  in  some  cases  the  spinous  processes  of  the  vertebrae  may  be 
readily  felt. 

If  the  elbow  presents,  it  is  recognized  by  being  smaller  than  the  knee, 
and  the  olecranon  pointed  while  the  patella  is  flat ;  if  there  be  doubt,  the 
forearm  should  be  extended,  and  the  hand  will  be  readily  recognized. 
The  elbow,  before  the  forearm  is  extended,  points  from  the  head.  Should 
the  hand  descend,  the  means  of  distinguishing  it  from  the  foot  men- 
tioned in  the  diagnosis  of  pelvic  presentation  are  to  be  used ;  there  is 
usually  no  difficulty  in  making  this  diagnosis.  But  it  does  not  neces- 
sarily follow  that  there  is  a  shoulder  presentation  because  the  hand 
descends,  for  this  may  happen  in  presentation  of  the  head,  or  of  the 
breech,  and  therefore  it  is  necessary  by  auscultation,  by  palpation,  and 
by  vaginal  touch,  to  know  that  the  prolapsed  hand  is  not  a  complication 
of  either  of  these  presentations.  Supposing  the  hand  to  descend  in  a 
shoulder  presentation,  it  is  important  to  know  whether  it  is  the  right  or 
left  hand.  Two  very  simple  ways  are  presented;  by  following  either, 
the  question  is  answered.  Put  yourself  in  its  place  and  shake  hands, 
That  is,  let  the  obstetrician  imagine  one  of  his  own  hands  occupying 
the  same  position,  and  he  at  once  knows  which  hand.  Or  let  him 
apply  one  of  his  own  hands  to  the  projecting  hand,  the  right,  for  exam- 
ple ;  if  palm  corresponds  with  palm,  and  the  thumbs  are  directly  applied 
to  each  other,  it  is  the  right  hand. 

The  hand1  gives  the  shoulder ;  the  back  of  the  hand  the  situation  of 
the  head ;  the  direction  of  the  thumb  indicates  the  direction  of  the 
breech  ;  when  the  breech  is  posterior,  the  thumb  is  directed  above  from 
the  side  of  the  pubic  joint ;  if  the  breech  is  anterior,  the  thumb  is 
directed  below,  toward  the  anus. 

Three  modes  of  spontaneous^  delivery  may  occur  in  shoulder  presen- 
tations : 

1.  As  observed  by  Roederer,  Kleinwachter,  and  others,  the  foetus 
may  be  delivered  doubled ;  but  this  is  only  possible  when  it  is  small, 
very  flexible,  and  compressible. 

2.  Spontaneous  version,  by  which  the  head  or  breech  is  substituted 
for  the  shoulder,  may  occur ;  if  the  head  take  the  place  of  the  shoulder, 
the  change  is  known  as  cephalic  version,  but  if  the  breech,  pelvic  ver- 
sion.    Spontaneous  version  has  been  attributed  to  the  active  movements 
of  the  ftetus  and  to  irregular  uterine  contractions.     It  would  seem 
more  natural  to  explain  the  change  as  resulting  from  the  uterus  taking, 
though  tardily,  its  normal  ovoidal  form,  and  compelling  the  foetal  ovoid 
to  occupy  its  corresponding  position. 

3.  Spontaneous  evolution  is  the  term  given  to  the  delivery  when,  the 

1  Charpentier. 


286  PHYSIOLOGY  OF  LABOR. 

shoulder  still  presenting,  a  series  of  changes,  or  mechanical  phenomena 
essentially  the  same  as  those  that  have  been  described  in  connection  with 
delivery  in  other  presentations,  take  place.  These  are : 

1.  Compression,  by  which  the  presenting  part  is  lessened  and  thus 
adapted  to  the  canal  through  which  it  must  pass. 

2.  Descent.     This  stage  requires  no  description. 

3.  Rotation  of  the  shoulder  into  the  pubic  arch.     These  three  stages 
occupy  considerable  time,  during  which  the  foetus  in  most  cases  dies. 
The  shoulder  is  the  smallest  part  of  the  foatal  wedge,  and  hence  advances 
first,  driven  in  the  direction  of  least  resistance.     With  the  rotation  of 
the  shoulder  the  head  moves  anteriorly  and  is  fixed  above  the  pubic  joint. 

4.  Delivery  of  the  body.     The  anterior  shoulder  remaining  fixed  at 
the  subpubic  ligament,  the  posterior  shoulder  is  forced  down  the  sacro- 
perineal  curve,  the  body  being  strongly  latero-flexed.     By  referring  to 
Figs.  131  and  132,  it  is  seen  that  the  right  shoulder  is  anterior  and 
remains  fixed,  while  the  left  or  posterior  shoulder  is  driven  further 
down  ;  the  latter  finally  passes  out  at  the  anterior  margin  of  the  perin- 
eum, and  is  followed   by  the  chest,  abdomen,  and  hips,  and  then  the 
anterior  shoulder  is  delivered,  the  head  only  remaining  in  the  pelvis. 

FIG.  131. 


SPONTANEOUS  EXPULSION.    FIRST  STAGE. 


5.  Internal  rotation  of  the  head  and  external  rotation  oj  the  body. 
This  is  the  same  as  that  which  occurs  in  pelvic  deliveries. 

6.  Delivery  of  the  head.    This,  too,  is  the  same  as  in  pelvic  deliveries. 
CAPUT  SUCCEDANEUM.     This  is  situated  upon  the  shoulder  which 

has  presented ;  when  the  arm  •  prolapses,  it  also  is  swelled  and  dis- 
colored, and  frequently  is  the  seat  of  phlyctenulse. 

Of  course,  shoulder  presentations  are  not  trusted  to  spontaneous 
delivery,  but  demand  the  intervention  of  art.     Nevertheless,  it  was 


THE  MECHANICAL  PHENOMENA  OF  LABOR.  287 

FIG.  132. 


SPONTANEOUS  EXPULSION.    SECOND  STAGE. 


important  to  present  nature's  method  of  dealing  with  these  abnor- 
malities. The  student  will  recognize  the  truth  of  the  statement 
made  at  the  beginning  of  this  exposition  of  the  mechanical  phenomena 
of  labor,  that  there  is  a  unity  in  this  mechanism,  one  general  plan,  one 
common  end.  That  this  may  be  made,  if  possible,  still  clearer,  the 


FIG.  133. 


SPONTANEOUS  EXPULSION.    THIRD  STAGE. 


288  PHYSIOLOGY  OF  LABOR. 

following  table,  including  the  different  presentations,  with  the  associated 
mechanical  phenomena  of  labor,  is  given  : 

Vertex  Presentation.  Face  Pretentation.  Pelvic  Pretentation.  Shoulder  Presentation. 


I.  Flexion    of     the 
head. 
2.  Descent. 
3.  Rotation  of  head. 
4.  Delivery  of  head. 
5.  Internal   rotation 
of  body. 
6.  Expulsion    of 
body. 

Extension  of   the 
head. 
Descent. 
Rotation  of  head. 
Delivery  of  head. 
Internal  rotation 
of  body. 
Expulsion    of 
body. 

Compression  of  pel- 
vis. 
Descent. 
Rotation  of  pelvis. 
Delivery  of  body. 
Internal  rotation  of 
head. 
Expulsion  of  head. 

Compression    of 
shoulder. 
Descent. 
Rotation  of  shoulder. 
Delivery  of  body. 
Internal  rotation  of 
head. 
Expulsion  of  head. 

PROGNOSIS  OP  VERTEX,  FACE,  AND  BREECH  PRESENTATIONS. 
Auvard  gives  as  the  mortality  for  infants,  when  the  vertex  presents,  1 
per  cent.,  in  facial  presentation  5  per  cent.,  and  in  pelvic  10  per  cent. 
But  this  is  too  favorable.  If  the  vertex  present  and  the  position  is 
occipito-anterior,  the  mortality,  according  to  Winckel,  is  2.5  per  cent. 
But  in  an  occipito-posterior  position,  with  rotation  posteriorly,  more 
than  15  out  of  100  perish.  In  presentation  of  the  face  13  per  cent, 
are  born  dead,  and  7.5  per  cent,  asphyxiated.  Pelvic  presentations 
give  a  mortality  of  about  20  per  cent. 

In  regard  to  the  infant  mortality  in  pelvic  presentation,  Runge  states 
that  it  varies,  according  to  different  authorities,  between  9  and  37  per 
cent.;  Kaltenbach  says  it  is  10,  20,  even  30  per  cent.  Porak,  on  the 
other  hand,  gives  1  infant  dead  in  9  primiparse  and  1  in  30  multipart. 
A  proper  conduct  of  the  labor  will  certainly  give  a  less  mortality  than 
that  which  has  been  quoted  from  eminent  German  authorities. 


CHAPTEE  XII. 

THE   CONDUCT   OF   LABOR. 

HAVING  considered  the  phenomena  of  labor,  its  conduct  or  manage- 
ment is  now  to  be  presented.  Giving  birth  to  a  child,  though  a  physi- 
ological function,  differs  very  materially  from  any  other  function  of  the 
organism.  These  differences  are  duration,  suffering,  and  traumatism. 
Intelligent  art  may  in  many  instances  shorten  the  first,  and  lessen  the 
second  and  third.  Even  admitting  that  the  savage  woman1  safely 
brings  forth  alone,  or  with  only  an  ignorant  attendant,  the  civilized 
woman  is  in  many  instances  very  far  from  being  in  a  physiological 
condition,  and  thus  childbirth  brings  to  her  peculiar  pains  and  perils; 
her  higher  development  renders  her  more  susceptible  to  bodily  suffer- 
ing, and  in  many  instances  has  been  attained  by  the  partial  sacrifice  of 
physical  endurance  and  vital  force.  Moreover,  in  cases  of  labor  for  a 
time  advancing  favorably,  sudden  accidents  imperilling  the  life  of 
mother  or  of  child  may  arise,  and  professional  knowledge  and  skill  be 
needed  to  meet  them  ;  while  the  common  role  of  the  obstetrician  is  "  to 
observe,  to  control,  to  alleviate,  and  to  protect,"  emergencies  may  come 
which  demand  his  promptest  action  and  greatest  ability,  though  it  is 
only  in  a  small  minority  of  births,  not  more  than  five  per  cent.,  any 
other  interference  is  required.  It  is,  therefore,  important,  in  her  own 
interest  and  in  that  of  her  offspring,  that  woman  should  have  in  labor 
a  qualified  professional  attendant. 

Two  important  questions,  the  one  relating  to  antisepsis,  the  other  to 
anaesthesia,  may  be  considered  at  the  beginning  of  this  exposition  of 
the  obstetrician's  duties. 

ANTISEPSIS.  With  our  present  knowledge  of  the  gravest  diseases 
which  affect  the  lying-in  woman.,  it  is  very  probable  they  are  caused  by 
microscopic  germs  ;  hence  it  is  important  that  woman  in  labor  should 
as  far  as  possible  be  protected  from  the  presence  of  such  germs,  and 
their  entrance  through  the  necessary  or  accidental  traumatisms  of  labor 
be  prevented.2  As  part  of  the  means  for  the  attainment  of  this  end,  it 

1  The  following  statement  is  made  by  Dr.  Engelmann  in  his  very  interesting  volume,  Labor 
Among  Primitive  Peoples,  p.  7 :    "Among  primitive  people,  still  natural  in  their  habits  and 
living  under  conditions  which  favor  the  healthy  development  of  their  physical  organization, 
labor  may  be  characterized  as  short  and  easy,  accompanied  by  few  accidents  and  followed  by 
little  or  no  prostration." 

If  birth  were  as  easy  as  that  of  Wenonah  in  Longfellow's  song  of  Hiawatha,  obstetricians 
would  never  be  needed : 

"  There  among  the  ferns  and  mosses, 
There  among  the  prairie  lilies, 
On  the  Muskoday,  the  meadow, 
In  the  moonlight  and  the  starlight, 
Fair  Nokomis  bore  a  daughter." 

2  The  testimony  given  by  lying-in  hospitals  in  regard  to  the  value  of  antiseptics  in  greatly 
lessening  not  only  mortality  but  morbidity  is  so  large  and  clear  that  no  intelligent  and  con- 
scientious practitioner  can  deny  that  system  or  wisely  ignore  the  use  of  such  agents.    The 
mortality  has  been  reduced  to  one-half  per  cent,  or  less,  and  the  statistics  of   Schuster,  of 
Innspruck,  show  that  of  the  women  delivered  there,  93.1  per  cent,  did  not  have  any  febrile 
temperature.— Centr.  f.  Gynakol.,  1888. 

19 


290  PHYSIOLOGY  OF  LABOR. 

is  important  that  the  lying-in  room  be  well  ventilated  and  free  from 
disease  germs  or  from  the  poisonous  influence  of  sewer-gas.  I  have 
seen  in  consultation  a  case  of  puerperal  septicaemia  in  a  multipara  who 
occupied  a  room  in  which  three  months  before  two  of  her  children  were 
ill  with  diphtheria ;  in  another  patient  the  lying-in  room  had  a  wash- 
stand  communicating  with  a  badly  drained  sev/er ;  in  a  third  the  dis- 
ease apparently  had  its  origin  in  connection  with  scarlet  fever,  the 
husband,  a  physician,  attending  some  malignant  cases  of  the  disease 
immediately  before  and  after  his  wife's  confinement,  and  spending  most 
of  his  time  in  her  room. 

Thorough  disinfection  of  the  room  which  the  patient  is  to  occupy 
should  be  made,  if  it  has  been  previously  occupied  by  one  suffering  with 
scarlet  fever,  with  erysipelas,  or  diphtheria,  or  with  any  disease  attended 
with  suppuration,  as  uterine  cancer  in  its  advanced  stages  ;  it  would 
be  better,  indeed,  for  her  lying-in  to  be  in  another  house  or  other 
room.  The  room,  too,  should  be  free  from  the  effluvia  of  decaying 
animal  matter.  If  there  be  any  sewer  communication  in  it,  as,  for 
example,  from  a  permanent  washstaud,  that  communication  should  be, 
for  the  time  at  least,  cut  off.  The  obstetrician  must  know  that  the 
nurse  has  not  recently  been  in  attendance  upon  any  of  the  forms  of 
disease  that  have  been  mentioned,  and  especially  upon  a  case  of 
puerperal  septicaemia. 

ANTISEPSIS  or  THE  PATIENT.  It  is  advisable  for  a  woman  at  the 
beginning  of  labor  to  have  a  whole  bath,  or  a  hip-bath  ;  after  this  the 
external  sexual  organs  are  washed  with  warm  water  and  soap,  and  then 
with  a  disinfectant  solution,  e.  g.,  3  per  cent,  of  carbolic  acid  or  1J  per 
cent,  of  lysol,  or  a  mixture  of  creolin  and  water  may  be  employed. 
Vaginal  injection,  or  irrigation,  is  not  indicated  unless  there  be  a  puru- 
lent discharge,  or  the  labor  is  protracted ;  the  antiseptic  used  in  the 
former  case  may  be  one  part  of  corrosive  sublimate  to  two  thousand  of 
water. 

ANTISEPSIS  OF  THE  OBSTETRICIAN.  In  addition  to  what  has  been 
said  on  this  subject,  page  190,  the  peril  of  the  patient  being  greater  in 
consequence  of  the  traumatisms  of  labor,  and  the  danger  of  infection  by 
the  physician  being  increased,  because  it  may  be  several  examinations 
are  made  instead  of  one,  so  his  precautions  must  be  more  complete.  It 
his  fingers  have  touched  infectious  matter,  not  only  the  thorough  washing 
with  soap  and  water  that  has  been  previously  mentioned — here  especially 
the  use  of  sand  and  green  soap  is  one  of  the  best  means  of  mechanical 
disinfection — but  before  immersing  them  in  the  corrosive  sublimate 
solution  they  are  to  be  washed  with  80  per  cent,  of  alcohol. 

Ribemont-Dessaignes  and  Lepage  say  that  there  is  not  a  single 
obstetric  antiseptic  which  is  good  on  every  occasion.  Corrosive  subli- 
mate, which  is  a  perfect  microbicide  in  practice,  is  an  agent  that  must 
be  prudently  employed,  because  of  its  toxicity,  and  because  of  the  acci- 
dents which  it  produces  when  absorbed  in  considerable  quantity.  The 
biniodide  has  been  proposed  as  a  substitute,  but  Tarnier  states  that  it 
has  less  antiseptic  power  and  presents  as  great  danger  of  poisoning. 

Naphtaline,  or  the  naphtolate  of  soda,  is  an  excellent  antiseptic,  4  to 
1000  of  water ;  it  has  proved  useful  both  as  a  vaginal  and  uterine 


THE  CONDUCT  OF  LABOR.  291 

injection.  But  it  must  be  freshly  prepared,  in  order  that  it  may  have 
sufficient  solubility,  and  therefore  it  can  hardly  come  in  general  use. 

The  sulphate  of  copper  has  proved  useful,  but  it  has  also  been  found 
dangerous.  Boric  acid  has  not  great  antiseptic  value,  but  it  is  to  be 
observed  that  Kaltenbach,  after  suggesting  a  5  per  cent,  mixture  of 
carbolic  acid  and  oil,  or  vaseline  free  from  germs,  for  anointing  the 
finger  which  is  used  in  touching,  commends  lanolin,  more  especially 
Graf's  boro-glycerin-lauolin  kept  in  tin  tubes. 

Potassic  permanganate1  in  solution  has  been  used  as  an  antiseptic, 
but  the  stains  which  it  leaves  have  made  it  objectionable. 

The  use  of  antiseptics  after  labor  will  be  considered  in  connection 
with  the  management  of  the  puerperal  state. 

ANESTHESIA.  HISTORICAL.  Early  in  1847  the  illustrious  Sir  Jarnes  Y. 
Simpson  proved  that  inhalation  of  sulphuric  ether  could  be  safely  and  success- 
fully used  for  the  relief  of  pain  in  childbirth,  and  later  in  the  year  he  established 
the  same  fact  as  to  the  inhalation  of  chloroform.  Obstetric  anaesthesia  soon 
found  a  few  in  Great  Britain  and  on  the  Continent  to  advocate  and  practise  it. 
In  the  United  States,  Dr.  N.  C.  Keep,  of  Boston,  was  the  first  American  physi- 
cian to  administer  an  anaesthetic  in  labor.  But  Dr.  Walter  Channing  was  the 
most  distinguished  of  American  physicians  advocating  the  practice ;  his  treatise 
on  Etherization  in  Childbirth  was  published  in  1848.  The  late  Professor  Henry 
Miller,  of  the  University  of  Louisville,  gave  chloroform  to  a  woman  in  labor  on 
the  13th  of  March,  1848 ;  this  was  the  first  time  that  chloroform  was  thus  used 
west  of  the  Allegheny  Mountains.  Dr.  Miller  remained  faithful  to  anaesthesia 
in  labor  the  rest  of  his  honored  life ;  he  strongly  advocated  the  practice,  and  with 
his  well-known  ability  answered  the  arguments  adduced  against  it.  Channing 
and  Miller  are  the  two  names  that  in  this  country  shine  with  the  most  lustre  in 
connection  with  the  early  advocacy  of  obstetric  anaesthesia. 

On  the  other  hand,  three  of  the  most  eminent  obstetric  teachers,  Meigs,  Hodge, 
and  Bedford,  strongly  opposed  the  use  of  anaesthetics  in  normal  labor,  and  their 
influence  was  more  powerful  than  that  of  its  advocates.  The  controversy  here 
was  but  the  reflex  of  that  which  was  occurring  in  Great  Britain.  Simpson 
asserted  that  it  was  only  a  question  of  time  as  to  the  general  adoption  of  anaes- 
thesia in  parturition.  On  the  other  hand,  Dr.  Ashwell,  who,  with  Tyler  Smith 
and  Eamsbotham,  were  the  most  prominent  London  obstetricians  opposing  the 
practice,  declared  that  "unnecessary  interference  with  the  providentially 
arranged  process  of  healthy  labor  is  sure,  sooner  or  later,  to  be  followed  by 
injurious  or  fatal  results,"  "  that  chloroform  need  only  be  extensively  used  to 
insure  its  entire  abandonment,"  and  that  it  was  "  a  duty  to  urge  every  plea  against 
its  further  use."  More  than  thirty-five  years  have  passed  since  these  words  of 
Simpson  and  of  Ashwell  were  uttered ;  the  prophets  are  dead,  but  the  prophecy 
of  neither  has  been  fulfilled ;  chloroform  has  not  been  generally  adopted,  nor 
has  it  been  entirely  abandoned  in  obstetric  practice. 

Doubtless  the  influence  of  Drs.  Meigs,  Hodge,2  and  Bedford  did  much  in  this 
country  to  prevent  the  use  of  anaesthetics  in  labor.  It  is  certain  that  the  great 
majority3  of  women  in  the  United  States  endure  the  martyrdom  of  maternity 
without  anaesthesia.  On  the  other  hand,  it  often  happens  that  a  brief  surgical 
operation,  in  many  instances  much  less  painful  than  childbirth,  is  not  done  until 
the  subject  is  anaesthetized. 

1  In  Dr.  Hunter  Robb's  useful  volume,  Aseptic  Surgical  Technique,  the  author,  in  describing 
the  process  of  sterilizing  the  hands,  advises  after  they  have  been  immersed  in  a  warm  saturated 
solution  of  permanganate  that  they  should  be  next  washed  in  a  warm  saturated  solution  of 
oxalic  acid,  and  adds:  "  Experiments  made  by  Dr.  Mary  Sherwood,  in  the  Pathological  Labora- 
tory of  the  Johns  Hopkins  University,  have  shown  that  in  this  process  the  oxalic  acid  and  not 
the  permanganate  of  potassium  is  the  essential  disinfecting  agent." 

2  And  yet  Dr.  Hodge,  while  refusing  the  parturient  the  relief  to  be  had  from  chloroform,  indi- 
cates the  severity  of  her  suffering  by  saying  that  she  is  "  agonized  and  serai-delirious." 

3  For  example,  in  the  Summary  of  Obstetric  Cases  reported  by  members  of  the  East  District 
Medical  Society,  and  compiled  by  Dr.  Samuel  W.  Abbott,  Boston  Medical  and  Surgical  Journal, 
Jaly  6,  1882,  in  only  twelve  per  cent,  were  anaesthetics  used  ;  as  showing  the  great  preference  by 
New  England  physicians  for  ether,  it  was  used  in  323,  and  chloroform  in  only  2  cases. 


292  PHYSIOLOGY  OF  LABOR. 

ANAESTHETIC  MEANS.  Chloroform1  is  preferred  by  most  to  ether, 
because  of  its  pleasanter  odor,  its  prompter  action,  and  the  less  quan- 
tity required.  Though  various  means  have  been  recommended  to  pro- 
duce obstetric  anaesthesia,  not  one  is  perfect.  If  there  could  be  found 
some  agent  Avhich,  while  annulling  pain,  would  have  no  injurious  effect 
upon  uterine  contractions,  lessening  their  force  and  frequency,  invariable 
in  its  action,  and  leaving  no  unfavorable  conditions,  it  would  be  the  best 
boon  to  women  enduring  the  martyrdom  of  maternity.  Chloroform  and 
sulphuric  ether  come  nearer  meeting  these  requirements  than  any  other 
of  the  various  means  that  have  been  recommended.  The  bromide  of 
ethyl,  according  to  Kaltenbach,2  only  exceptionally  has  a  favorable 
action,  and  is  transitory,  and  moreover  is  liable  to  leave  irritation  of 
the  respiratory  mucous  membrane.  The  combination  of  laughing-gas 
and  oxygen,  4  : 1,  cannot  often  be  readily  had,  and  a  sufficient  supply 
would  be  cumbersome.  Hypnotism  is  uncertain,  only  few  readily  and 
completely  yield  to  its  influence,  and  seldom  does  the  obstetrician  pos- 
sess hypnotic  power ;  moreover,  neuroses  may  follow  its  employment. 
Chloral  is  warmly  recommended  by  some  obstetricians,  fifteen  to  twenty 
grains  every  thirty  minutes  until  pain  is  lessened,  and  it  may  be  given 
by  mouth  or  rectum ;  but  it  is  slowly  absorbed,  and  it  cannot  be  as  well 
regulated  according  to  the  needs  of  the  case  as  anaesthetic  inhalation. 
The  local  application  of  cocaine  is  very  limited  in  its  adaptability,  the 
exposure  of  the  genital  canal  in  pencilling  the  cervix,  for  example,  is 
not  a  matter  of  indifference  so  far  as  the  future  safety  of  the  patient  is 
concerned.  The  effect  is  transient,  and,  finally,  an  injurious  amount  of 
the  drug  may  be  absorbed. 

Kaltenbach  objects  to  chloroform  on  the  ground  that  it  lessens  the 
number,  duration,  and  force  of  the  uterine  contractions.  Ahlfeld3 
states  that  hemorrhage  in  the  placental  period  is  more  liable  to  occur  if 
chloroform  has  been  used,  partly  from  the  feebleness  of  uterine  con- 
tractions, and  partly  from  the  lessened  coagulability  of  the  blood.  He 
also  believes  it  dangerous  to  the  child.  Since  the  first  of  1893  Ahlfeld 
has  used  ether,  and  is  quite  satisfied  with  it. 

Kaltenbach  believes  that  ether  has  a  less  unfavorable  effect  than 
chloroform,  and  that  acting  as  a  cardiac  stimulant  it  is  of  service  in  the 
anaemic.  Ribemout-Dessaigues  and  Lepage,4  considering  only  chloro- 
form in  labor,  observe  "  that  in  the  great  majority  of  cases  women 
ought  to  be  delivered  without  chloroform ;  but  that  in  some  whose 
nervous  system  is  too  excitable,  or  if  the  uterus  contracts  with  too  much 
violence,  resort  to  chloroform  analgesia  may  be  made,  especially  if  the 
patient  insists  upon  it."  Martin5  says  that  the  severe  suffering  can  be 
blunted  by  superficial  narcosis  without  interfering  with  the  abdominal 
pressure,  and  that  a  few  drops  of  chloroform  may  be  given  by  inhala- 
tion at  the  beginning  of  each  pain  in  the  second  stage  of  labor;  but  if 
this  stage  is  long,  the  energy  of  the  abdominal  pressure  is  occasionally 
thereby  injuriously  affected. 

It  is  quite  evident  from  the  statements  of  authors  referred  to  that  the 

1  The  late  Dr.  Fordyce  Barker  informed  me  that  he  always  used  chloroform,  and  that  he  used  it 
in  all  cases  of  labor. 

2  Op.  cit.  '  Op.  cit.  «  Op.  cit. 
5  Lehrbuch  der  Geburtshilfe,  1891. 


THE  CONDUCT  OF  LABOR.  293 

employment  of  anaesthesia  in  labor  is  far  from  general,  and  is  even 
hesitatingly  employed. 

The  writer  knows  but  little  from  personal  experience  of  the  employ- 
ment of  chloroform,  but  he  has  frequently  used  ether,  and  his  belief  is 
that  the  latter  may  be  safely1  and  beneficially  employed  in  the  second 
stage  of  labor  in  the  majority  of  women.  But  the  practitioner  should 
remember  that  the  anaesthesia  must  be  neither  continuous  nor  profound ; 
intermittences  in  the  administration  are  important,  and  at  no  time  must 
the  intelligence  and  will  of  the  patient  be  suspended. 

Dr.  J.  C.  Reeve,  in  his  contribution  to  the  American  System  of  Obstetrics, 
"On  the  Use  of  Anaesthetics  in  Labor,"  denies  that  ether  is  a  safer  anaesthetic 
than  chloroform,  and  after  a  careful  study  of  accidents  from  chloroform  in  labor 
makes  the  following  statements  : 

1.  But  one  well-authenticated  case  of  death  is  on  record  where  the  adminis- 
tration was  by  a  medical  man,  and  in  that  case  no  autopsy  was  held. 

2.  Dangerous  symptoms  have  occurred  but  a  very  few  times,  and  then  almost 
always  from  violation  of  the  rules  of  proper  administration. 

3.  The  danger  when  chloroform  is  used  only  to  the  extent  of  mitigation  or 
abolition  of  the  suffering  of  childbirth  is  practically  nil ;  when  carried  to  the 
surgical  degree  for  obstetric  operations,  the  danger  is  far  below  what  it  is  in 
surgery. 

4.  No  proof  can  be  furnished  that  the  parturient  woman  enjoys  a  special  im- 
munity from  the  danger  of  anaesthetics,  although  facts  seem  to  indicate  that  such 
exists.  Her  best  safeguard  lies  in  the  care  and  watchfulness  of  the  administrator. 

If  chloroform  be  employed,  it  may  be  inhaled  from  a  handkerchief 
or  small  napkin,  upon  which  half  a  teaspoonful  is  poured  at  a  time ; 
the  napkin  or  handkerchief  is  held  close  to,  but  not  touching,  the 
patient's  nose.  For  the  administration  of  ether  an  extemporaneous  in- 
haler may  be  made  by  first  making  a  cone  of  a  stiff  towel,  then  this 
cone  is  surrounded  at  the  sides  and  covered  upon  the  top  by  thick,  firm 
paper ;  a  sponge  as  large  as  the  fist  is  pressed  into  the  cavity  of  the 
cone  and  saturated  with  ether,  being  careful  that  the  quantity  is  not  so 
great  as  to  drip  upon  the  patient's  face  when  the  instrument  is  used. 
The  hollow  base  of  the  cone  is  now  placed  so  as  closely  to  encircle  the 
patient's  mouth  and  nose.  The  anaesthetic  is  not  to  be  used  except  just 
before  and  during  a  "  pain,"  .the  purpose  being  not  to  cause  uncon- 
sciousness, but  to  lessen  or  remove  suffering  while  intelligence  and  will 
remain  in  full  exercise. 

Anaesthetic  inhalation  is  used  in  the  second,  rarely  in  the  first  stage 
of  labor.  It  may,  however,  exceptionally  be  of  value  in  the  latter  ;  for 
example,  in  the  case  of  a  primipara  if  the  "  pains "  are  unusually 
severe  and  the  os  dilates  very  slowly,  the  new  experience  wearies, 
weakens,  and  disheartens  her,  and  great  nervous  irritability  ensues  ; 
but  now  blunt  the  sharp  edge  of  her  suffering  by  an  anaesthetic,  and  a 
happy  change  may  occur  in  her  mental  and  physical  condition.  In 
general,  the  indication  for  anaesthesia  is  great  suffering,  no  matter 
whether  this  occur  in  the  first  or  in  the  second  stage  of  labor.  Dr.  J. 
C.  Reeve,  of  Dayton,  Ohio,  whose  name  is  so  well  known  in  counec- 

1  Porak,  Societe  Obstetricale  et  Gynecologic,  of  Paris,  1890,  stated  that  chloroform  appears  to 
offer  the  least  uncertainty  as  an  obstetric  anaesthetic,  but  he  also  said  that  the  more  rapid  elimin- 
ation of  ether  probably  renders  it  less  dangerous. 


294  PHYSIOLOGY  OF  LABOR. 

tion  with  the  subject  of  anaesthesia,  states1  that  "  the  periods  of  labor 
to  which  it  is  best  adapted  are  two  :  when  distention  is  greatest  of  the 
os,  and  of  the  vulva.  The  kind  of  labor  where  it  does  best  is  that  in 
which  energy  of  contractions  is  great  and  expulsive  force  is  in  excess 
of  dilatation." 

In  all  cases  the  practitioner  will  be  guided  by  the  effect  of  the  anaes- 
thetic, withholding,  lessening,  or  increasing,  as  may  be  indicated ;  he 
will  never  carry  the  anaesthesia  so  far  as  to  suspend  consciousness,  unless 
during  the  birth  of  the  head,  and  after  it  is  born  the  use  of  the  auses- 
thetic  should  stop. 

SPECIAL  DIRECTIONS.  Prompt  attendance  is  important  when  called 
to  a  case  of  labor,  for  though  in  most  instances  the  call  comes  earlier 
than  necessary,  yet  occasionally  the  presence  of  the  obstetrician  may 
enable  him  easily  to  correct  an  unfavorable  presentation,  which  later 
may  prove  difficult  or  impossible,  or  arrest  a  dangerous  hemorrhage,  or 
avert  an  attack  of  eclampsia. 

The  following  articles  should  be  carried  by  the  accoucheur:  A  stetho- 
scope, a  flexible  catheter,  a  preparation  of  ergot,  a  solution  of  morphine, 
or  tablets  for  preparing  such  solution  for  hypodermatic  use,  and  syringe, 
sulphuric  ether,  two  or  three  long  needles  with  silk,  silkworm-gut,  or 
properly  prepared  catgut,  to  be  used  if  the  perineum  is  torn,  and,  if 
the  patient  lives  at  considerable  distance,  an  obstetric  forceps.2 

If  the  patient  has  not  already  been  provided  with  a  fountain  syringe, 
with  an  antiseptic  solution,  and  an  anaesthetic — chloroform,  or  ether,  or 
a  solution  of  chloral — the  obstetrician  should  carry  these  too ;  on  the 
other  hand,  if  the  anaesthetic  selected  be  ether,  and  she  has  a  supply, 
it  will  be  unnecessary  to  include  it  in  the  list  first  mentioned.  Upon 
arrival  it  is  better  that  he  should  not  immediately  enter  the  patient's 
room,  even  if  previously  knowing  her ;  especially  if  a  stranger,  and 
taking  the  place  of  her  expected  attendant,  his  coming  should  be  first 
announced,  for  an  abrupt  entrance  may  have  an  unfavorable  effect  upon 
her.  Admitted  to  her  room,  it  is  rarely  necessary  for  him  to  make  an 
immediate  examination,  or  even  at  once  to  inquire  as  to  her  present 
condition  ;  for  a  time  at  least,  it  is  better  for  him  to  get  his  information 
indirectly,  by  observing  the  character  of  her  pains,  their  frequency, 
regularity,  and  the  apparent  suffering  they  cause.  Let  him  so  guard 
his  words  and  acts  that  no  offence  be  given  to  woman's  modesty,  which 
is  at  once  her  ornament  and  defence.  Physical  suffering  hushes  the  cry 
of  shame,  and  until  this  occurs  many  a  woman  will  shrink  from  a  vag- 
inal examination,  especially  if  abruptly  proposed.  The  obstetrician 
should  be  a  gentleman,  gentle  in  his  ways  and  words,  and  yet  firm  in 
conduct ;  he  among  all  men  must  have  the  suamter  in  modo  as  well  as 
thefortiter  in  re. 

Two  questions  are  to  be  decided  by  the  professional  attendant  when 
in  the  presence  of  a  patient  supposed  to  be  in  labor.  First,  is  she  preg- 
nant? Second,  has  labor  begun?  A  woman  is  very  rarely  deceived  as 
to  the  fact  of  her  own  pregnancy,  but  occasionally  she  may  have  a  false 

1  Private  communication. 

2  The  conservatism  of  Blundell  did  not  permit  taking  instruments.    "  Lead  not  yourselves  into 
temptation ;  if  you  put  your  instruments  into  your  pocket,  they  are  very  apt  to  slip  out  of  your 
pocke's  into  the  uterus." 


THE  CONDUCT  OF  LABOR.  295 

instead  of  a  true  pregnancy,  and  the  physician  must  have  the  possibility 
of  such  occurrence  in  his  mind.  Provided  the  professional  attendant 
does  not  already  know,  inquiry  is  made  as  to  the  date  of  the  last  men- 
struation, and  as  to  that  of  "quickening;"  so  the  question  may  be  asked 
as  to  the  premonitory  symptoms  of  labor;  if  she  has  been  previously  con- 
fined, the  character  of  the  labor  or  labors  should  be  ascertained.  Next, 
inquiry  may  be  directed  as  to  her  present  condition,  how  long  she  has 
been  sick,  whether  the  "pains"  are  regular  in  recurrence,  whether  in- 
creasing in  frequency  and  severity,  and  where  they  are  felt;  whether 
she  has  other  suffering  than  that  of  labor,  headache,  for  example,  and 
whether  there  have  been  recent  and  free  discharges  from  the  bladder  and 
rectum.  The  necessity  for  an  examination,  if  she  does  not  already  know 

FIG.  134. 


EXAMINATION  IN  LABOR  WITH  INDEX  FINGER  OF  RIGHT  HAND.  THE  Os  UTERI  JUST  OPENING. 

i 

it,  is  explained  to  her,  and  as  a  rule  her  consent  is  readily  given.  The 
physician  retires  from  the  room  while  the  nurse  makes  the  necessary 
preparations  by  arranging  the  person  and  the  clothing  of  the  patient. 
Very  commonly,  upon  his  return,  the  woman  will  be  found  lying  upon 
the  side  with  the  hips  near  the  edge  of  the  bed,  this  position  being  taken 
as  less  offensive  to  modesty.  Though  a  vaginal  examination  can,  in 
most  cases,  be  made  more  satisfactorily  if  the  woman  be  in  the  dorsal 
position,  and  this  position  is  essential  for  abdominal  palpation,  an  imme- 
diate change  need  not  be  required,  but  after  examining  while  she  is 
lying  upon  the  side,  she  may  be  requested  to  turn  upon  the  back,  and 
the  exploration  continued  and  completed.  After  the  examination,  exter- 
nal as  well  as  interual,  the  methods  and  purposes  of  which  have  been 
fully  explained,  and  the  physician  finding  a  normal  presentation  with 
favorable  position,  vigorous  and  regular  action  of  the  uterus,  and  good 


296 


PHYSIOLOGY  OF  LABOR. 


condition  of  the  birth-canal,  he  should  frankly  tell  the  woman  and  her 
friends  that  "everything  is  right,"  according  to  the  stereotyped  expres- 
sion, or  make  some  equivalent  statement. 


FIG.  135. 


EXAMINATION*  IN  LABOR  WITH  Two  FINGERS  OF  THE  LEFT  HAND,  THE  Os  UTERI  MORE  DILATED. 

Possibly  the  patient,  after  being  informed  of  the  favorable  condition 
of  affairs,  asks  how  soon  the  labor  will  be  over.  The  question  is  sure 
to  come  sooner  or  later,  and  to  be  anxiously  and  wearily  repeated  if  the 
labor  be  long.  Let  the  obstetrician  beware  of  a  positive  answer,  espe- 
cially if  it  be  the  first  stage  of  labor,  and  if  a  primipara,  for  the 
remorseless  clock  may  contradict  his  prediction  at  the  sacrifice  of  all  her 
hopes  and  of  her  confidence  in  him.  Velpeau  remarked : 

The  accoucheur  who,  in  order  to  make  a  show  of  vain  wisdom,  thinks  himself 
capable  of  telling  exactly  when  the  labor  will  terminate,  not  only  exposes  his 
ignorance  or  his  bad  faith,  but  he  compromises  the  honor  of  his  art  and  the  safety 
of  his  patient.  Gooch,  referring  to  parturition  in  a  primipara,  said,  "  I  am  never 
fool  enough  to  state  any  time  within  which  the  labor  will  be  over." 

It  sometimes  happens  that  the  first  stage  is  brief  and  the  second  pro- 
tracted ;  or,  again,  the  first  unusually  long  and  the  second  very  short ; 
and  hence  any  answer  as  to  the  duration  of  the  labor,  founded  upon 
the  presentation  and  position,  the  primiparity  or  the  multiparity  of  the 
patient,  the  condition  of  the  soft  parts,  the  proportion  between  the  pre- 
senting part  and  the  birth-canal,  derived  from  observing  the  rate  of 
progress  in  a  definite  time,  can  only  be  a  probability  and  an  approxi- 
mation to  the  truth,  and  should  be  so  stated.  Here,  as  in  the  general 


THE  CONDUCT  OF  LABOR.  297 

relations  of  physician  and  patient,  the  laws  of  truth  must  be  observed* 
not  that  in  all  cases  the  patient  is  to  be  informed  of  any  great  peril 
that  threatens  her,  but,  on  the  other  hand,  let  no  falsehood  ever  be  told 
her.  Lying  to  patients,  though  the  motive  may  be  a  kind  one,  never 
brings  any  good  in  the  long  run ;  and  he  who  does  it  leads  himself  into 
temptation  to  be  untruthful  upon  other  occasions,  even  if  he  does  not 
forfeit  his  claim  to  be  believed  in  all  matters,  and  loses  his  own  self- 
respect  and  also  that  of  those  who  know  him. 

It  is  well  to  explain  to  her,  if  this  is  her  first  experience,  the  dif- 
ferent stages  of  labor,  the  value  of  voluntary  effort  in  the  second,  and 
its  inutility  and  injury  in  the  first  period.  Better,  too,  that  she1  should 
know  what  she  has  to  endure,  and  the  greatness  of  her  suffering  be 
acknowledged,  rather  than  treat  it  as  being  slight ;  and  never  try 
to  cheat  her  with  false  hopes  and  promises  that  will  not  be  fulfilled. 
We  are  dealing  with  a  rational  being,  and  intelligent  faith,  will,  and 
conscience  are  a  stronger  support  in  the  endurance  of  great  suffering 
than  blind  hope  and  unfulfilled  predictions. 

PREPARATION  OF  THE  BED  AND  OF  THE  PATIENT'S  PERSON. 
These  duties  are  generally  attended  to  by  an  intelligent  nurse ;  but 
sometimes  the  nurse  is  not  intelligent,  or  the  patient  may  be  too  poor 
to  employ  one,  or  the  labor  ends  before  her  coming,  and  in  such  emer- 
gencies the  practitioner  must  direct  or  make  the  necessary  preparation 
of  the  bed.  The  bedstead  should  not  be  close  to  the  wall,  but  accessible 
at  each  side ;  a  firm  mattress  is  laid  upon  it,  and  over  the  mattress  a 
piece  of  rubber  sheeting,  oilcloth,  or  tarred  paper  to  protect  it  from 
the  patient's  discharges,2  for  these  absorbed  by  it  would  cause  both 
discomfort  and  danger.  Above  the  protective  material  an  old  quilt  or 
comforter,  first  folded  lengthwise,  and  then  transversely,  is  placed  on 
that  part  of  the  bed  where  the  patient's  hips  will  rest,  and  above  this 
a  sheet  similarly  folded.  Now  let  a  sheet  be  spread  in  the  usual  man- 
ner upon  the  bed,  then  folded  from  below  above  so  that  the  fold  will 
come  higher  than  the  quilt  and  sheet  which  have  been  put  in  place ; 
this  sheet  is  thus  arranged  that  it  may  be  protected  from  being  soiled 
during  labor,  and  after  that  has  ended,  and  all  wet  clothes  have  been 
removed,  it  can  be  drawn  down  under  the  hips  and  to  the  foot  of  the 
bed,  thus  securing,  with  the  least  disturbance  of  her  person,  a  dry, 
clean,  and  warm  sheet  to  lie  upon. 

Instead  of  the  method  just  given,  it  is  very  common  to  have  the  under  sheet 
extend  over  the  rubber  cloth  to  the  foot  of  the  bed,  then  upon  this  there  will  be 
placed  a  draw-sheet,  made  by  folding  a  sheet  four  times  in  its  length,  and  put 

1  The  great  poetess  of  the  century,  Mrs.  Browning,  who  knew  from  her  own  experience  what 
the  suffering  of  childbirth  was,  has  thus  described  it : 

"I  appeal 

To  all  who  bear  babes !    In  the  hour 
When  the  vail  of  the  body  we  feel 
Rent  round  us,  while  torments  reveal 

The  motherhood's  advent  in  power." 

There  might  be  added  the  words  that  Euripides  has  put  in  the  mouth  of  Medea : 
"  Thrice  would  I  stand  on  the  rough  edge  of  battle 
Ere  once  bear  the  pangs  of  childbirth." 

2  Dr.  T.  G.  Davis,  Bridgeton,  N.  J.,  informs  me  that  instead  of  a  quilt  he  uses  ne\yspapers, 
more  likely  to  be  aseptic,  and  over  them  a  sheet ;    the  papers  are  readily  had,  absorb  discharges 
well,  and  afterward  are  burned. 

The  expression  used  by  old  English  writers,  among  others  Lord  Bolingbroke  and  Dean  Swift,  for 
lying-in  was  "being in  the  straw."  Should  the  practice  suggested  prevail,  there  might  be  sub- 
stituted "  being  in  the  newspapers,"  a  condition  to  which  not  only  many  women,  but  also  men, 
including  some  doctors,  are  not  averse ! 


298  PHYSIOLOGY  OF  LABOR. 

upon  that  part  of  the  bed  where  the  patient's  hips  rest,  and  secured  by  safety- 
pins.  Rubber  cloth  now  is  placed  so  as  completely  to  cover  and  protect  the 
draw-sheet;  next  there  may  be  laid  upon  the  rubber  a  folded  blanket,  or  com- 
forter, and  finally  a  sheet  also  folded.  After  the  labor  is  over  every  article  down 
to  the  draw-sheet  is  removed,  and  that  is  changed  from  day  to  day  when  it  be- 
comes soiled. 

In  some  parts  of  the  country  it  is  customary  to  prepare  a  large  muslin  sac 
and  half-fill  it  with  bran,  which  is  placed  under  the  hips  of  the  parturient,  and 
readily  absorbs  all  fluids  that  are  discharged ;  it  is  removed  after  the  labor. 

When  the  patient  lies  down,  in  the  second  stage  of  labor,  her  chemise 
and  nightdress  should  be  drawn  up  above  the  hips,  and  a  twice-folded 
sheet  pinned  around  the  latter;  this  is  far  preferable  to  the  skirt  which 
is  often  worn  at  such  a  time,  for  the  latter  is  not  so  easily  removed,  and 
its  removal  almost  inevitably  causes  some  soiling  of  the  lower  limbs. 
A  piece  of  old  carpet  or  of  oilcloth  is  spread  on  the  floor  at  that  side 
of  the  bed  upon  which  the  patient  lies. 

MANAGEMENT  OF  THE  FIRST  STAGE  OF  LABOR.  During  this 
stage,  the  presentation  being  normal,  and  the  general  condition  good, 
the  patient  ought  not  to  be  in  bed ;  sitting,  walking,  or  standing  is 
more  favorable  for  the  entrance  of  the  head  into  the  pelvic  cavity  than 
lying ;  moreover,  if  she  is  up  now,  the  necessary  confinement  to  the 
bed  in  the  second  stage  of  labor  will  be  less  irksome.  She  may  be 
encouraged  to  engage  in  some  light  occupation  or  in  cheerful  conversa- 
tion, so  that  the  time  will  not  drag,  and  her  mind  will  in  some  degree 
be  diverted  from  her  suffering.  Few  persons  should  be  in  the  room, 
and  those  only  who  are  agreeable  companions  to  her,  and  who  will 
abstain  from  exciting  her  fears  by  the  manifestation  of  great  anxiety, 
by  gloomy  looks  and  untimely  forebodings,  or  by  narrating  the  mis- 
fortunes of  other  women  in  labor  or  in  childbed.  Her  sympathies  and 
her  antipathies  ought  to  be  consulted  in  regard  to  those  who  are  with  her, 
and  the  obstetrician  who  knows  how  wisely  to  observe  and  judiciously 
to  act  can  often  regulate  this  matter  to  the  great  benefit  of  the  patient. 

CONDITION  OF  BLADDER  AND  RECTUM.  If  these  organs  have  not 
been  recently,  and  cannot  be  spontaneously,  emptied,  artificial  means 
must  be  used.  It  very  seldom  happens  that  there  is  urinary  retention, 
but  accumulation  of  feces  is  common  ;  the  best  means  for  the  relief  of 
the  latter  will  be  an  enema  of  water,  or  of  soap  and  water. 

FOOD,  DRINK.  Usually  there  is  very  little  desire  for  food  during 
labor,  but  if  it  be  protracted  the  patient  should  take  nourishment  in 
some  form  lest  she  become  exhausted ;  she  may  have  any  simple  food 
she  desires,  care  being  taken  that  the  stomach  is  not  overloaded.  The 
most  grateful  drink  will  be  cold  water,  and  that  may  be  taken  freely. 
On  the  other  hand,  hot  teas,  so  often  in  the  country  urged  in  domestic 
practice  upon  the  parturient  by  injudicious  friends  with  the  purpose  of 
"  making  the  pains  stronger,'7  as  well  as  alcoholic  stimulants,  ought  to 
be  forbidden. 

ACTIVE  INTERFERENCE  WITH  THE  PROCESS  OF  DILATATION. 
There  is  a  notion1  on  the  part  of  some  women  .that  the  doctor  can  and 

i  Some  years  ago  I  saw  a  woman  who  had  a  torn  cervix  and  perineum,  and  she  explained  her 
condition  as  resulting  from  the  fact  that  "  the  doctor  opened  "  her  "  up  too  much  "  when  she  gave 
birth  to  her  child. 


THE  CONDUCT  OF  LABOR.  299 

ought  to  render  important  assistance  in  the  physiological  processes  of 
childbirth  by  mechanical  or  other  means.  Some  doctors,  too,  advocate 
and  pursue  this  practice.  Dr.  Barnes  has  justly  characterized  digital 
dilatation  of  the  os  uteri  as  "old  and  bad." 

The  danger  of  septic  infection  by  manual  dilatation,  and  by  all  unnecessary 
examinations,  has  been  strongly  presented  by  Spiegelberg  in  considering  the 
prophylaxis  of  puerperal  septicaemia :  "  Care  must  be  taken  that  labor  go  on  as 
simply  as  possible ;  manipulations  in  the  genital  passages  are  to  be  made  only 
when  absolutely  necessary.  .  .  .  Nothing  is  more  objectionable  and  more 
repulsive  than  the  almost  incessant  exploring  and  manipulating  in  the  vagina, 
the  os  uteri,  and  the  vulva,  which  most  midwives  are  in  the  habit  of  doing  when 
the  labor  does  not  progress  as  rapidly  as  they  desire.  .  .  .  The  danger  in 
this  for  the  puerpera  cannot  be  too  strongly  emphasized." 

The  young  practitioner  may  be  assured  that  digital  dilatation  of  the 
as  uteri,  or  of  the  os  vulva?,  is  rarely  necessary ;  in  most  cases  does  no 
good,  and  in  some  may  do  much  harm. 

Among  the  other  means  resorted  to  for  shortening  the  first  stage  of 
labor  may  be  mentioned  the  administration  of  ipecacuanha  in  an  emetic 
dose,  a  practice  which  was  never  common  and  which  is  now  becoming 
almost  unknown,  and  the  application  of  belladonna  to  the  cervix,  or,  as 
advised  by  Horton,2  the  injection  of  a  solution  of  atropine  into  its  sub- 
stance. I  can  say  nothing  in  favor  of  any  of  these  means  from  per- 
sonal experience,  but  in  normal  labor  they  are  unnecessary. 

It  may  be  added  that  an  8-10  grain  solution  of  cocain  applied  to  the 
margin  of  a  resisting  or  rigid  os  often  proves  useful. 

PRESENCE  OF  THE  PHYSICIAN.  It  is  not  advisable  for  the  physi- 
cian to  remain  constantly  in  the  room  during  the  first  stage  of  labor ; 
an  occasional  absence  gives  the  patient  an  opportunity  to  evacuate  the 
bladder,  to  make  changes  in  her  clothing,  or  attend  to  other  matters 
which  might  be  prevented  by  his  presence.  Further,  if  he  constantly 
stays  in  the  room  she  may  anticipate  a  speedier  termination  of  her 
labor  than  is  possible,  or  she  may  think  her  condition  serious ;  beside 
this,  he  may  be  appealed  to  by  her  or  by  her  friends  to  render  some 
supposed  assistance,  which  may  be  very  injudicious  or  even  injurious. 
In  many  cases  it  is  not  necessary^  for  him  even  to  remain  in  the  house, 
and  he  may  take  the  opportunity  to  visit  other  patients ;  but  it  should 
always  be  known  where  he  can  be  found,  if  any  emergency  arise  de- 
manding his  immediate  presence.  A  physician  may  exhaust  his  strength 
by  too  constant  attendance  and  too  assiduous  attention  during  the  first 
stage  of  labor,  and  by  denying  himself  needed  sleep,  so  that  when  some 
serious  difficulty  arises  in  the  second  or  third  stage  he  may  lack  the 
clear  head,  the  firm  hand,  and  the  physical  endurance  upon  which  the 
salvation  of  his  patient  or  of  her  child  rests. 

MANAGEMENT  OF  THE  SECOND  STAGE  OF  LABOR.  The  uterine 
contractions  are  reinforced  by  voluntary  efforts,  and  the  first  usually 
passes  into  the  second  stage  of  labor  by  a  gradual  transition.  The  pa- 
tient now  goes  to  bed,  her  clothing  being  arranged  as  has  been  mentioned ; 
but  if  a  primipara,  or  if  the  labor  be  slow,  it  is  not  necessary  for  her  to 

1  American  Journal  of  Obstetrics,  1878. 


300  PHYSIOLOGY  OF  LABOR. 

remain  constantly  lying  down ;  occasional  sitting  up,  or  taking  a  few 
turns  in  the  room,  will  give  her  some  rest,  and  also  may  hasten  de- 
livery. 

At  the  beginning  of  this  stage  the  bag  of  waters  usually  ruptures ; 
and  it  is  not  advisable  to  rupture  it  if  the  labor  is  progressing  favorably. 
Should  this  be  necessary  simply  pressing  the  finger  against  it  during  a 
uterine  contraction  will  generally  answer ;  if  such  pressure  does  not  suc- 
ceed, a  few  notches  may  be  cut  in  the  finger-nail1  making  a  saw  of  it,  which 
may  then  be  thus  used  against  the  tense  membranes.  Immediately  after 
the  escape  of  the  amnial  liquor  a  vaginal  examination  must  be  made,  in 
order  to  confirm,  in  some  instances  possibly  to  correct,  the  diagnosis  of 
presentation  and  position  that  has  been  made,  or  to  make  this  diagnosis 
if  it  has  hitherto  been  impossible,  and  to  ascertain  any  change  of  posi- 
tion, or  any  increase  in  descent  of  the  presenting  part,  which  in  a  multi- 
para  may  sometimes  become  very  rapid  immediately  after  the  evacua- 
tion of  the  fluid;  so,  too,  this,  examination  is  now  necessary,  in  order  to 
ascertain  whether  prolapse  of  the  cord,  or  of  one  of  the  upper  or  lower 
limbs,  has  occurred. 

POSITION  OF  THE  PATIENT.  It  varies  in  different  countries,  but 
with  us  she  usually  lies  upon  the  back,  or  upon  the  left  side.  Until 
the  head  rests  upon  the  pelvic  floor  the  most  favorable  position  during 
a  pain  is  one  between  sitting  and  lying,  the  feet  pressed  against  a  firm 
object,  or  the  bent  knees  fixed  by  the  pressure  of  the  hands  of  one  of 
the  attendants,  the  upper  portion  of  the  trunk  drawn  forward  by  the 
patient  grasping  the  hands  of  the  nurse  or  a  sheet  or  towel  fastened  to 
the  lower  part  of  the  bed  for  this  purpose,  and  the  chin  turned  to  the 
chest.  A  kneeling1  or  squatting  position  is  the  most  favorable  for  the 
expulsion  of  the  child,  but  the  child  may  be  injured,  the  perineum  can- 
not be  protected,  the  liability  to  hemorrhage  is  greater,  and  it  is  impossi- 
ble to  manage  properly  the  third  stage  of  labor,  as  well  as  difficult  to 
put  the  patient  in  bed.  When  lying  upon  the  left  side  the  usual  right 
obliquity  of  the  uterus  is  corrected,  and  in  this  regard  the  uterine  force 
acts  more  advantageously ;  the  abdominal  pressure,  however,  is  less, 
and  the  general  force  is  directed  too  much  in  the  direction  of  the  axis 
of  the  inlet — that  is,  toward  the  fundus  of  the  pelvic  cylinder — whereas 
the  line  of  exit  for  the  foetus  is  nearly  at  a  right  angle  to  that  of  en- 
trance. Many  women  prefer  the  side  position  because  of  the  relief  to 
pain  in  the  back  which  firm  pressure  of  the  hand  upon  the  sacrum 
gives;  such  pressure,  of  course,  cannot  be  made  when  the  patient  lies 
on  her  back.  Schroder  has  proved  that  rupture  of  the  perineum  is 
more  frequent  in  women  delivered  upon  the  back  than  in  those  delivered 
upon  the  side,  and  therefore  the  latter  position  should  be  taken  in  all 
cases  in  which  there  is  danger  of  such  rupture  as  soon  as  the  head 
begins  to  press  upon  the  pelvic  floor.  In  this  position,  too,  visual  ex- 
amination of  the  perineum,  should  it  be  necessary,  is  possible. 

1  It  has  been  objected  to  this  method  that  in  these  days  when  the  obstetrician  must  have  short 
finger-nails,  to  avoid  furnishing  a  refuge  for  septic  stuff,  this  cannot  be  done,  and  instruments  have 
been  invented  for  piercing  the  membranes — a  matter  of  ingenuity  to  make  and  of  money  to  buy  ! 
A  bodkin,  which  can  be  found  in  every  house,  after  disinfection,  may  be  used,  if  the  finger-nail  is 
too  short ;  or  a  probe  or  director  from  a  pocket-case  will  answer. 

2  Kleimvachter. 


THE  CONDUCT  OF  LABOR.  301 

WALCHER'S  POSITION.  A  Venice  physician,  in  1738,  advised  the  patient  in 
labor  to  be  placed  horizontally  on  a  table  or  bed,  so  that  her  lower  limbs  would 
hang  over  its  edge.  It  has  recently  been  claimed  by  Walcher  that  this  position 
increases  the  true  conjugate  8-18  mm. ;  Klein  states  that  the  increase  is  only 
5-6  millimetres. 

My  friend  and  colleague,  Dr.  Forbes,  assures  me  that  such  increase  is  very 
doubtful.  Certainly  the  force  thus  resulting  cannot  be  compared  with  that 
exerted  by  the  wedge-like  action  of  the  foetal  head  when  driven  or  drawn  through 
the  pelvis.  It  is  possible  that  Walcher's  position  will  pass  into  oblivion,  as  did 
that  of  which  it  is  merely  the  echo. 

[f  CONDITION  OF  THE  CHILD.  Occasional  inquiry  may  be  made  of  the 
patient  as  to  her  being  conscious  of  the  movements  of  the  child.  But 
a  more  certain  way  of  learning  its  condition,  either  in  the  first  or  second 
stage  of  labor,  is  by  auscultation.  The  first  indication1  of  the  suffer- 
ing of  the  child  is  shown  by  a  greater  rapidity  of  the  cardiac  pulsa- 
tions ;  then,  if  this  state  continues,  to  the  acceleration  which  appears  at 
first  there  succeeds  a  slowing,  which  becomes  more  and  more  decided  as 
the  foetal  life  is  more  and  more  compromised.  At  the  same  time  that 
these  variations  are  observed  and  irregularities  are  produced,  the  inten- 
sity of  the  bruits  lessens.  Whenever,  says  Depaul,  the  cardiac  pulsa- 
tions fall  below  100,  and  especially  below  80,  the  condition  is  a  very 
serious  one,  and  if  possible  the  accoucheur  ought  to  intervene  and  end 
the  labor. 

CONDITION  OF  THE  Os  UTERI.  As  has  been  stated,  the  rule  is  that 
in  the  first  stage  of  labor  attempts  to  dilate  the  os  uteri  by  the  fingers 
should  not  be  made ;  so,  too,  they  are  usually  not  required  in  the  second 
stage.  But  as  it  sometimes  happens  that  in  the  former  the  force  of  the 
uterine  contractions  is  in  part  lost  in  consequence  of  the  os  being  directed 
too  far  posteriorly  and  to  the  side,  and  it  may  be  then  advantageous  to 
hook  the  fingers  into  the  os  during  the  absence  of  a  pain,  and  draw  it 
toward  the  centre  of  the  pelvic  cavity,  keeping  it  in  this  position  during 
a  contraction,  so  in  the  second  stage  the  anterior  margin  of  the  os  may 
be  found  closely  applied  to  the  foetal  head,  while  the  posterior  has 
receded,  hence  liberation  of  the  former  is  indicated.  The  part  of  the 
foetal  head  in  front  descends  at  each  contraction,  hooded  by  the  anterior 
portion  of  the  dilated  cervix,  and  this  portion  thus  compressed  between 
the  head  of  the  foetus  and  the  pelvic  wall  is  liable  to  become  swelled 
and  oedematous.  Therefore,  by  the  advice  of  the  most  conservative 
obstetricians,  this  part  may  be  pressed  up,  in  the  intervals  of  contrac- 
tions, by  one  or  two  fingers,  and  thus  held  during  a  uterine  effort ;  some- 
times the  head  immediately  passes  the  obstruction,  but  in  others  it  may 
be  necessary  once  or  oftener  to  repeat  the  proceeding.  Let  it  be  remem- 
bered that  this  manoeuvre,  which  is  seldom  necessary,  must  be  done 
without  violence. 

CRAMPS  IN  THE  LOWER  LIMBS.  Cramps  affecting  the  thighs  or 
legs  sometimes  cause  great  suffering ;  they  occur  in  the  second  rather 
than  in  the  first  stage  of  labor,  and  are  attributed  to  pressure  and  drag- 
ging upon  certain  nerves  of  the  pelvis,  branches  of  the  sacral  plexus, 
the  sciatic,  the  obturator,  etc.  Rubbing  the  affected  part  with  the  hand, 
change  of  position,  or  the  use  of  an  anaesthetic  will  give  relief. 

1  Depaul,  op.  cit. 


302  PHYSIOLOGY  OF  LABOR. 

FOOD,  DRINK,  ETC.  PREPARATION  FOR  DELIVERY.  Unless  the 
second  stage  be  unusually  long  the  patient  rarely  desires  or  needs  nourish- 
ment ;  a  full  stomach  will  hinder  the  needed  voluntary  effort  during  a 
uterine  contraction  ;  if  food  is  given,  only  a  small  quantity  is  advisable, 
and  it  should  be  simple  and  easily  digested.  Now,  as  then,  cold  water 
may  be  taken  as  desired.  Frequently  bathing  the  patient's  hands  and 
face  with  cool  water  will  in  most  cases  be  both  agreeable  and  refreshing. 

When  the  second  stage  approaches  its  end,  hot  and  cold  water,  an 
alcoholic  stimulant,  scissors,  and  a  string  for  tying  the  cord  are  to  be  at 
hand. 

Pressure  of  the  head  upon  the  rectum  often  causes  a  factitious  desire 
to  empty  the  bowels,  and  the  patient  insists  upon  getting  up  for  this 
purpose ;  but  she  must  be  refused,  for  the  child  might  be  born  while  she 
was  on  the  commode  or  in  the  water-closet. 

CARE  OF  THE  PERINEUM.  Usually  the  most  important  of  the  ob- 
stetrician's active  duties  in  the  second  stage  of  labor  is  protection  of  the 
perineum  from  being  torn  during  the  delivery  of  the  head  and  shoulders 
of  the  foatus,  or,  if  a  tear  is  inevitable,  cause  that  to  be  as  slight  as  pos- 
sible. 

Matthews  Duncan  and  Schroder  have  shown  that  in  primiparas  some 
tearing  of  the  vaginal  orifice  is  inevitable,  and  the  rent  may  involve  the 
perineum,  only  39  per  cent.,  according  to  the  latter,  escaping  rupture  of 
the  fourchette.  Not  only  injury  of  the  posterior  portion  of  the  vulva, 
but  also  of  its  anterior  may  occur,  and  the  rents  in  some  cases  cause 
serious  hemorrhage.  The  perineum  is  especially  liable  to  tear  from  the 
direction  of  the  force  which  propels  the  child  through  the  birth-canal ; 
it  is  a  resisting  wall  designed  to  direct  the  foetus  toward  the  opening  in 
the  anterior  portion  of  the  dynamic  pelvis.  When  the  perineum  gives 
way  the  rent  generally  occurs  in  the  median  line,  for  there  the  disten- 
tion  is  greatest  and  the  tissues  are  furthest  from  their  points  of  attach- 
ment. Even  if  the  perineum  receives  no  injury  immediately  apparent, 
it  may  have  been  subjected  to  pressure  for  so  long  a  time  and  been  so 
greatly  stretched  that,  though  entire  for  some  days  after  delivery,  it 
finally  gives  way,  and  the  condition  is  then  similar  to  laceration.  Hib- 
berd1  has  reported  two  cases  of  the  kind,  and  Duncan2  previously 
directed  attention  to  the  fact,  but  a  case  of  such  injury  was  first  described 
by  Dewees.3 

FREQUENCY  OF  RUPTURES  OF  THE  PERINEUM.  Taking  hospital 
statistics  rather  than  any  derived  from  private  practice,  it  is  probable 
that  the  perineum  is  more  or  less  torn  in  20  to  30  per  cent,  of  primi- 
parse,  and  in  5  to  10  per  cent,  of  multipart. 

CAUSES.  Without  referring  to  special  conditions  of  the  parts  creating 
a  liability  to  the  accident,  or  the  form  of  the  pelvis,  or  certain  presenta- 
tions and  positions,  it  may  be  in  general  stated  that  the  great  majority 
of  perineal  tears  occur  from  too  rapid  deliveries,  the  child  being  expelled 
before  there  is  sufficient  dilatation  of  the  vulvo-vaginal  opening;  the 
force  is  too  great,  and  the  time  too  short,  so  that  soft  parts  are  not 
stretched  but  ruptured. 

1  American  Practitioner,  1881.  -  Papers  on  the  Female  Perineum,  1879. 

8  System  of  Midwifery,  eighth  edition,  p.  287, 1837. 


THE  CONDUCT  OF  LABOR.  303 

PREVENTION.  It  follows  from  the  statement  just  made  that,  to  pre- 
vent a  tear  of  the  perineum,  or  to  make  the  tear  as  slight  as  possible  if 
some  injury  be  inevitable,  the  most  important  means  are  to  hinder  abrupt 
expulsion  of  the  foetus,  and  to  promote  gradual  dilatation  of  the  part  it 
traverses.  In  attaining  these  objects  one  of  the  first  things  to  be  done 
is  to  have  the  patient  lie  upon  her  side,  preferably  the  left  side.  The 
advantages  of  the  lateral  position  are  lessened  voluntary  effort,  prevent- 
ing the  wide  separation  of  the  thighs,  and  in  this  position  the  condition 
of  the  perineum  may  be  known,  if  necessary,  by  actual  inspection. 
There  must  be  no  pressure  against  her  knees,  and  any  object  against 
which  her  feet  may  push  should  be  removed ;  she  should  be  directed 
to  take  frequent  respirations,  and  to  refrain  from  all  bearing-down 
efforts ;  if  such  efforts  cannot  be  thus  prevented,  chloroform  may  be 
given.  A  doubled  pillow  or  a  quilt  made  into  a  roll  is  placed  between 
her  knees.  If  the  dilatation  of  the  vulval  opening  be  insufficient,  the 
head  must  be  held  back  by  direct  pressure,  and,  when  it  is  finally 
expelled,  it  should  be  guided  during  the  expulsion  in  the  axis  of 
the  opening.  Hohl  directed  grasping  the  head,  after  the  occiput  has 
passed  under  the  pubic  joint,  with  the  hand,  the  thumb  above,  the 
fingers  below  reaching  to  the  anterior  margin  of  the  perineum,  and 
thus  holding  the  head  back  during  a  pain.  Others  apply  pressure  to 
the  head  with  one  hand,  while  the  other  is  used  to  support  the  per- 
ineum.1 

Supporting  the  perineum  is,  as  Matthews  Duncan  has  remarked,  a 
practice  upheld  by  the  majority  of  obstetricians,  both  now  and  in  past 
times. 

In  many  cases  the  condition  of  the  perineum  as  to  ready  dilatability 
is  such,  the  expulsive  force  acts  so  regularly  and  moderately,  and  the 
relation  of  the  object  to  be  expelled  is  so  adapted  to  the  outlet  of  the 
birth-canal,  that  there  is  no  danger  of  injury,  and  therefore  no  effort 
should  be  made  to  support  it;  the  obstetrician's  only  duty  then  is  to 
receive  in  his  hand  the  head  of  the  child  as  it  is  expelled.  But  in  other 
cases  the  following  plan  may  be  followed:  Supposing  the  patient  to  be 
lying  upon  her  left  side,  and  her  hips  quite  near  the  edge  of  the  bed,  the 
practitioner  places  his  right  hancl  so  that  the  concave  palm  receives  the 
convexity  formed  by  the  bulging  perineum;  the  thumb  is  upon  the 
right,  and  the  four  fingers  upon  the  left  labium  majus,  while  the  fold 
between  the  thumb  and  index  finger  corresponds  with  the  anterior  mar- 
gin of  the  perineum.  Moderate  resistance  is  made  to  the  force  driving 
the  head  against  the  perineum,  and  at  the  same  time  the  head  is  gently 
pressed  toward  the  pubic  symphysis ;  strong  pressure  is  to  be  avoided, 
because  if  the  perineum  be  very  thin,  such  pressure  at  this  thinned  part- 
may  cause  a  central  tear.  No  napkin  should  be  interposed  between  the 
hand  and  the  perineum ;  the  hand  is  not  applied  until  perineal  distention 
begins,  and  the  application  is  only  during  a  pain.  The  left  hand  is 
passed  over  the  patient's  upper  thigh,  and  grasps  the  foetal  head  in  the 
manner  directed  by  Hohl,  holding  it  back  when  necessary,  and  at  the 
proper  time  guiding  its  exit  in  the  axis  of  the  vulval  orifice. 

1  In  the  first  edition  I  gave  various  means  for  saving  the  perineum  advised  by  different  authori- 
ties—Siebold,  Bernati,  Ritgen,  Smellie,  Goodell,  Keamy,  Price,  and  others. 


304 


PHYSIOLOGY  OF  LABOR. 


A  clearer  understanding  of  the  mechanism  of  permeal  tears,  aud  of 
their  prevention,  will  be  had  by  examining  the  subjoined  diagram  taken 
from  Varnier,  and  in  connection  with  it  the  suboccipital  diameters  as 
shown  in  Fig.  93.  In  Fig.  136  it  will  be  seen  that  the  parietal  protu- 
berances have  just  cleared,  or  are  about  clearing,  the  vulval  ring,  aud 
that  the  stiboccipito-bregmatic  diameter  lies  directly  antero-posteriorly. 
But  in  order  that  the  head  may  be  born  a  longer  diameter,  and  conse- 
quently a  larger  circumference,  must  be  in  relation  with  the  ring;  this 
change,  as  has  hitherto  been  generally  taught,  occurs  by  a  partial  rota- 
tion of  the  head,  the  beginning  of  deflection,  or  as  taught  by  Berry 
Hart — his  views  will  be  more  fully  presented  in  a  moment — by  a  pro- 
gression, and  thus  there  is  not  even  the  least  deflection  of  the  head,  no 
pivoting  of  a  fixed  point  of  the  nucha  upon  the  pubic  joint.  But 
without  reference  to  either  view  just  given,  the  danger  of  perineal  rup- 


FIG.  136 


HEAD  ABOUT  TO  PASS  THE  VULVAL  OPENING. 

ture  comes  with  the  rapid  advance  of  the  head  before  retraction  of  the 
perineum  can  occur,  for  the  perineum  does  not  need  to  be  elongated  at 
this  stage — elongation  means  delay  or  rupture,  length  is  not  required, 
but  breadth ;  its  own  elasticity  determines  retraction,  aud  in  the  retrac- 
tion diminished  length  gives  increased  breadth.  By  moderating  abdom- 
inal and  uterine  action,  and  by  retarding  the  abrupt  exit  of  the  head, 
letting  the  perineum  withdraw  from  the  head  rather  than  the  latter 
advance  from  the  former,  we  best  preserve  it  from  injury.  If  this  view 
be  correct,  then  many  of  the  methods  advised  for  protecting  the  perineum 
are  useless,  and  some  are  most  unn'atural  and  mischievous,  proceedings 
that  thwart  rather  than  assist  nature's  method.  Give  the  perineum 
time  to  draw  back  when  the  greatest  strain  upon  the  vulval  opening 
comes,  aud  it  can  be  better  protected  than  in  any  other  way. 

Support  of  the  perineum  must  be  continued  during  the  passage  of 
the  shoulders  lest  a  new  rent  be  made,  or  a  slight  one  caused  by  the 
expulsion  of  the  head  be  increased. 


THE  CONDUCT  OF  LAS  OR.  305 

Hart  denies1  that  the  chin  leaves  the  sternum  while  passing  the  perineum,  and 
that  during  the  anterior  fixation  of  the  occiput  under  the  pubic  arch  antero- 
posterior  and  increasing  diameters  of  the  foetal  head  form  the  antero-posterior 
diameters  of  the  girdle  of  resistance.  His  method  of  "  protecting  the  perineum 
from  undue  tear  "  is  this  :  "All  the  attendant  can  do,  apart  from  the  familiar 
means  of  relaxing  perineal  spasm  by  chloroform  and  hot  applications,  is  to  pre- 
vent the  sinciput  being  forced  down  in  advance  of  or  faster  than  the  occiput. 
He  restrains  the  foetal  head  from  passing  too  rapidly.  He  thus  has  always  to 
get  the  occiput  to  lead,  and  to  get  it  fully  born  if  possible.  So  far  as  I  can  judge, 
the  best  way  of  doing  this  is  as  follows :  With  the  patient  lying,  of  course, 
upon  her  left  side,  the  attendant  places  the  thumb  of  his  right  hand,  guarded  by 
a  napkin  soaked  in  hot  sublimate,  in  front  of  the  anus  and  presses  it  gently 
there.  The  pressure  is  not  in  the  direction  of  a  line  joining  his  thumb  and  the 
pubic  arch,  but  nearly  in  that  of  the  pelvic  outlet.  By  this,  descent  of  the  sin- 
ciput is  hindered,  and  that  of  the  occiput  favored.  When  the  latter  is  beginning 
to  pass  under  the  pubic  arch  the  fingers  of  the  same  hand  are  placed  between  it 
and  the  apex  of  the  arch,  so  that  when  the  occiput  has  cleared  the  arch  the 
fingers  are  passed  toward  the  nape  of  the  neck,  and  the  head  thus  grasped  in 
the  hand,  ^:ie  thumb  lying  over  the  sagittal  suture.  This  gives  one  complete 
command  over  the  head  which  is  now  engaging  in  the  diameters  between  the 
nape  of  the  neck,  and  forehead  and  face,  and  allows  the  whole  passage  with  as 
little  tear  as  possible." 

EPISIOTOMY.  If  a  serious  tear  of  the  perineum  seems  inevitable, 
many  advise  that  an  incision  or  incisions  be  made  to  prevent  this  acci- 
dent. This  practice,  though  generally  credited  to  Michaelis,  1810,  was 
recommended  by  Ould2  1742. 

Opinions  differ  as  to  the  necessity  for  incisions,  and  also  on  the  part  of  those 
who  approve  of  the  operation  as  to  where  they  should  be  made.  The  late  Dr. 
A.  H.  McClintock  stated  that  he  had  so  often  seen  the  perineum  escape  lacera- 
tion, where  this  accident  seemed  inevitable,  he  was  led  to  doubt  the  possibility 
of  recognizing  the  cases  in  which  incision  is  an  absolute  necessity.  Playfair 
asserts  that  when  a  distended  perineum  ruptures  its  structures  are  so  thinned 
that  the  tear  is  always  linear ;  and,  as  a  matter  of  fact,  the  edges  of  the  wound 
are  always  as  clean  and  as  closely  in  apposition  as  if  the  cut  had  been  made 
with  a  knife.  This  statement  may  be  received  with  some  doubt,  even  by  those 
who  have  never  examined  a  recent  tear  of  the  perineum. 

The  incisions  usually  recommended  are  lateral.  Tarnier,  however,  states  that 
they  do  not  always  prevent  even  quite  extensive  tears,  and  they  may  leave  de- 
formity and  a  painful  cicatrix,  or  the  duct  of  one  of  the  vulvo-vaginal  glands 
may  be  divided  and  a  fistula  result.  He  therefore  advises  an  incision  of  the  per- 
ineum, beginning  at  the  raphe,  and  then  not  passing  directly  back,  but  turning 
obliquely  to  one  side,  so  that  if  a  laceration  follow,  it  cannot  involve  the  same 
sphincter.  He  cautions  against  episiotomy,  unless  ft  is  quite  indispensable,  for 

1  Edinburgh  Obstetrical  Society's  Transactions,  vol.  xii.    It  must  be  conceded  that  extension  is 
impossible  while  the  perineal  band  is  stretched  over  the  frontal  bone — that  band  must  hold  the 
chin  upon  the  sternum ;  but  once  the  forehead  clears  the  perineal  margin,  or,  which  amounts  to 
the  same  thing,  the  perineum  retracts  over  the  forehead,  extension  canl>egin — very  slight  indeed 
at  first,  but  increasing  until  the  head  completely  emerges,  its  perfect  delivery  being  followed  by  a 
dropping  down  of  the  head,  a  return  of  partial  flexion,  which  would  be  impossible  if  there  had 
not  oeen  some  extension. 

2  "  It  sometimes  happens,  though  the  Labour  has  succeeded  so  well  that  the  Head  of  the  Child 
has  made  its  Way  through  the  Bones  of  the  Pelvis,  that  it  cannot  however  come  forward,  by  reason 
ox  the  Extraordinary  Constriction  of  the  external  Orifice  of  the  Vagina ;  so  that  the  Head,  after 
it  has  passed  the  Bones,  thrusts  the  Flesh  and  Integuments  before  it,  as  if  it  were  contained  in  a 
Purse  ;  in  which  Condition,  if  it  continues  long,  the  Labour  will  become  dangerous,  by  the  Orifice 
of  the  Womb  contracting  about  the  Child's  Neck ;  wherefore  it  must  be  dilated  if  possible  by  the 
Fingers,  and  forced  over  the  Child's  Head  :  if  this  cannot  be  accomplished,  there  must  be  an  In- 
cision made  toward  the  Anus  with  a  Pair  of  crooked  Probe-Sizars ;  introducing  one  Blade  between 
the  Head  and  Vagina,  as  far  as  shall  be  thought  necessary  for  the  present  Purpose,  and  the  Busi- 
ness is  done  at  one  Pinch,  by  which  the  whole  Body  will  easily  come  forth." — A  Treatise  on  Mid- 
wifery.   By  Fielding  Ould,  Man-Midwife.    Dublin,  1742.    Ould  also  advised  stitching  the  wound 
if  the  incision  be  made  so  near  the  "  Rectum  as  to  weaken  its  Contraction." 

20 


306  PHYSIOL OG  Y  OF  LABOR. 

he  has  sometimes  seen  the  incised  parts  covered  with  eschars,  and  become  the 
medium  of  grave  infectious  accidents. 

Delore,  in  referring  to  the  lateral  incisions  advised  by  Dubois,  states  that  he 
accepts  in  extreme  cases  this  slight  operation,  but  in  ordinary  cases  it  is  prefer- 
able to  have  a  median  rent,  which  cicatrizes  uniformly,  than  two  lateral  ones, 
which  result  in  deformed  cicatrices. 

It  may  be  stated  that  episiotomy  will  very  seldom  be  plainly  indicated,  and  in 
private  practice  will  rarely  be  done. 

Dr.  Broomall1  regards  episiotomy  as  a  safe  and  justifiable  procedure  when  the 
perineum  is  threatened,  and  where  the  danger  of  deep  laceration  is  evident,  as 
the  proper  and  indispensable  means  to  be  used  with  the  hope  of  meeting  that 
danger.  She  advises  a  probe-pointed  curved  bistoury  to  be  used ;  the  blade  is 
slipped  between  the  foetal  head  and  the  lateral  margin  of  the  vaginal  orifice,  and 
its  cutting-edge  directed  during  a  pain  toward  the  tuber  ischii ;  the  incision  is 
made  at  a  point  one-third  the  distance  from  the  posterior  commissure  to  the 
clitoris;  the  length  of  the  incision  never  exceeded  1.5  centimetres.  A  similar 
incision  is  made,  if  necessary,  at  the  opposite  side ;  after  the  labor,  the  edges  of 
the  wounds  are  united  by  silk  sutures.  Dr.  Manton2  strongly  advocates  episi- 
otomy, claiming  that  it  diminishes  the  frequency  of  perineal  rupturesjto  a  mini- 
mum. He  also  operates  with  a  probe-pointed  bistoury,  and  makes  an  incision 
from  1  to  3  centimetres  long,  first  on  one,  and  then,  if  necessary,  on  the  other 
side ;  he  thinks  it  better  not  to  include  the  external  skin  in  the  incision,  although 
no  harm  is  done  should  this  be  done. 

DELIVERY  OF  THE  SHOULDERS.  Immediately  after  the  head  is 
expelled  and  rests  in  the  hand  of  the  accoucheur  a  finger  is  passed  to 
the  neck  of  the  child  to  find  if  the  cord  encircles  it,  an  accident  occur- 
ring once  in  rive  cases ;  if  this  be  the  case,  the  loop  must  be  enlarged, 
and  an  attempt  made  to  draw  it  over  the  head  ;  if  this  fails,  the  shoulders 
are  to  be  delivered  through  the  loop.  In  some  cases  the  cord  encircles 
the  neck  not  only  once  but  even  three  or  four  times,  and  the  coils  may 
be  so  tight  that  dividing  the  cord  is  necessary ;  if  this  be  done,  it  is 
advisable,  unless  the  fetus  is  immediately  delivered,  to  tie  the  fetal  end 
of  the  severed  cord. 

Moderate  pressure  is  made  upon  the  patient's  abdomen  during  the 
expulsion  of  the  body,  the  hand  so  placed  that  it  "  follows  down  "  the 
uterus  as  it  descends,  with  the  discharge  of  its  contents,  in  the  abdominal 
cavity.  The  shoulders  are  usually  delivered  soon  after  the  head  ;  any 
delay  can  generally  be  remedied  by  moderate  manual  pressure  or  friction 
of  the  uterus  through  the  abdominal  wall ;  it  may  be  advisable  in  some 
cases  to  turn  the  head  of  the  fetus  with  the  occiput  toward  the  mother's 
left  or  right  thigh,  according  as  the  position  was  left  occipital  or  right 
occipital,  thus  having  the  external  rotation  of  the  head  invite  and  cor- 
respond with  the  internal  rotation  of  the  shoulders;  then  let  the  head, 
still  held  in  the  hand,  drop  down  so  that  slight  traction  is  exercised 
upon  the  anterior  shoulder,  which  may  be  thus  liberated.  After  the 
anterior  shoulder  comes  in  the  pubic  arch  the  head  is  to  be  carried  up 
toward  the  mons  veneris,  slight  traction  being  made,  when  the  posterior 
shoulder  will  be  delivered ;  the  injunction  is  repeated,  during  the 
delivery  care  must  be  taken  that  the  perineum  escapes  injury. 

DIFFICULT  DELIVERY  OF  THE  SHOULDERS.  In  some  cases,  however,  the 
delivery  of  the  shoulders  cannot  be  thus  accomplished  ;  the  body  is  very  large, 
and  the  fcetal  circumference  of  the  shoulders  and  chest  much  greater  than  usual, 

1  American  Journal  ol  Obstetrics,  1878.  2  Ibid,  1885. 


THE  CONDUCT  OF  LABOR,  307 

while  the  vis  a  tergo,  the  uterine  and  abdominal  contraction,  may  fail.  The  diffi- 
culty may  be  increased  by  the  child's  breathing,  for  thereby  the  circumference 
of  the  chest  is  increased.  Danger  comes  to  the  child  from  compression  of  the 
chest,  or  of  the  cord,  which  may  encircle  the  body,  and  death  is  inevitable  unless 
speedy  delivery  can  be  effected.  One  of  the  ways  which  may  be  quickly  tried  is 
to  exert  traction  with  the  hands  applied  to  the  sides  of  the  child's  head.  Even 
if  we  cannot  complete  the  delivery  of  the  shoulders  in  this  way,  we  may  advance 
it  so  far  that  a  finger  can  be  readily  introduced  into  the  axilla  of  the  perineal 
shoulder,  and  then  pull  with  this  finger;  or  traction  may  be  made  with  the 
fingers  in  each  axilla.  Jacquemier,  who  gave  special  study  to  this  difficulty  in 
labor,  and  found  that  in  26  cases  20  of  the  children  died,1  advised  bringing  down 
the  arms,  upon  which  traction  can  be  made,  and  beside,  when  they  are  disen- 
gaged the  size  of  the  chest  is  lessened.  Although  the  practice  is  indorsed  by 
Charpentier,  he  acknowledges  that  in  one  case  he  fractured  the  humerus :  if 
there  be  room  for  this  manipulation,  there  is  room,  as  Spiegelberg  taught,  for 
delivery  by  other  methods,  and  it  may  be  rejected.  Hodge  advised  pushing  the 
anterior  shoulder  in  behind  the  pubic  joint,  then  bringing  the  neck  of  the  child 
in  the  pubic  arch,  so  that  its  side  presses  against  the  subpubic  ligament ;  by  this 
means  the  posterior  shoulder  is  brought  to  the  margin  of  the  perineum ;  when 
such  change  has  been  effected  the  head  is  carried  backward  and  the  anterior 
shoulder  again  comes  just  outside  the  pubic  arch,  and  delivery  is  usually  easily 
effected.  This  plan  was  also  advised  by  Spiegelberg.  Occasionally  it  may  be 
necessary  to  use  a  blunt  hook,  instead  of  the  finger,  to  exert  traction  from  the 
axilla ;  one  must  be  careful,  however,  not  to  act  upon  the  humerus  on  account  of 
risk  of  detachment  of  the  epiphysis ;  after  either  traction  by  finger  or  blunt 
hook  temporary  paralysis  of  the  arm  may  occur.  Of  course,  the  patient  should 
be  urged  to  "  bear  down,"  and  uterine  action  stimulated  by  friction  and  assisted 
by  external  abdominal  pressure. 

DELIVERY  OF  THE  REST  OF  THE  BODY.  After  the  delivery  of  the 
shoulders  the  remaining  portion  of  the  body  is  in  general  very  promptly 
expelled  ;  but  if  it  is  not,  and  immediate  delivery  is  necessary,  the  hands 
should  grasp  the  thorax,  and  with  gentle  traction  the  process  is  com- 
pleted. It  is  very  much  better,  however,  in  most  cases,  to  trust  the 
expulsion  of  the  child  to  the  uterus. 

ATTENTION  TO  THE  CHILD.  The  child  is  laid  upon  the  bed  at  the 
side,  not  so  near  that  by  any  sudden  movement  it  may  roll  off,  and  not 
so  far  from  the  mother  that  there  is  any  dragging  upon  the  c<  >rd ;  it  is 
placed  where  it  can  get  air,  and  in  a  position  in  which  it  will  not  be 
bathed  in  the  fluids  that  often  make  a  pool  about  the  mother's  hips.  It 
usually  at  once  breathes  freely  and  cries  vigorously  ;  if  respiration  be 
hindered  by  accumulation  of  mucus  in  its  mouth,  the  secretion  must  be 
wiped  away  by  the  linger  covered  with  a  little  soft  muslin.  In  case 
respiratory  efforts  are  feeble  or  absent,  they  generally  may  be  quickened 
or  excited  by  dashing  one  or  two  teaspoonfuls  of  cold  water  upon  the 
chest,  or  friction  of  the  chest  may  be  made  by  the  obstetrician  with  one 
of  his  hands  upon  which  a  small  quantity  of  spirits  of  camphor  has 
been  poured. 

It  was  the  custom  of  Mauriceau,  Clement,  La  Motte,  and  Deventer, 
indeed,  of  the  old2  obstetricians  generally,  not  to  tie  the  cord  until  the 
placenta  was  expelled ;  Zweifel  has  revived  this  practice,  and  he  uses 

1  I  have  met  with  this  hindrance  to  delivery  in  three  cases  in  which  the  child  could  not  be 
extracted  soon  enough  to  prevent  death.    The  method  advised  by  Hodge  and  Spiegelberg  I  think 
the  best.    In  some  instances  the  delivery  is  impossible  until  the  size  of  the  chest  is  lessened. 

2  Denman,  without  reference  to  the  expulsion  of  the  placenta,  stated  that  "  the  navel-string  of 
a  newborn  infant  ought  not  be  tied  or  divided  till  the  circulation  iu  it  has  ceased  spontaneously." 


308  PHYSIOLOGY  OF  LABOR. 

but  a  single  ligature.     Most  obstetricians,  however,  are  in  the  habit  of 
ligating  the  cord  as  soon  as  the  child  breathes  freely. 

Some  experiments,  made  by  Buclin1  in  1875,  in  immediate  and  late  ligation  of 
the  cord,  proved  that  when  the  latter  plan  was  followed  the  infant  received  a 
large  quantity  of  blood,  the  average  was  92  grammes,  and  thus  immediate  liga- 
tion deprived  the  infant  of  this.  In  March,  1885,  he  stated  that  almost  all  con- 
tributions to  the  subject,  published  in  different  countries,  confirm  the  general 
conclusion  which  he  had  previously  reached,  viz.,  ligation  and  section  of  the 
cord  should  not  be  done  until  after  complete  cessation  of  the  vascular  pulsations 
of  the  cord.  Not  merely  is  the  child  by  late  ligation  secured  a  notable  amount 
of  blood  otherwise  left  in  the  placenta,  but  its  subsequent  condition  is  more 
favorable,  it  loses  less  weight  in  the  first  days  following  birth,  and  acquires 
weight  more  rapidly  than  a  child  in  whose  case  immediate  ligation  was  done. 
These  were  the  conclusions  not  only  of  Budin,  but  also  of  Blbemont,  Schiicking, 
Zweifel,  and  of  most  who  investigated  the  subject.  The  matter  has  been  studied 
anew  by  Engel.2  He  observed  that  the  pulsations  in  the  cord  continue  for  some 
minutes,  or  even  for  a  quarter  of  an  hour,  after  birth.  He  found  that  late  liga- 
tion secured  to  infants  born  at  term  70  grammes,  but  to  premature  infants  90 
grammes.  Engel  failed  to  discover  any  relation  between  loss  of  weight  in  the 
first  days  after  birth,  but  his  statistics  prove  that  late  ligation  secures  increased 
vitality  to  the  infants.  Thus  the  mortality  of  premature  infants  when  immediate 
ligation  was  done  was  18.88  per  cent,  but  with  late  ligation  only  9.45  per  cent. 
The  reserve  blood  which  the  foetus  obtains  in  late  ligation  has  been  explained 
as  entering  partly  through  thoracic  aspiration  and  partly  through  pressure  upon 
the  placenta  while  it  is  squeezed  out  of  the  uterus.  But  Cariglia3  has  proved 
that  respiration  has  no  effect  in  this  process,  and  it  is  therefore  solely  due  to  the 
pressure  mentioned. 

In  regard  to  waiting  until  all  pulsation  has  ceased,  one  might,  in  some  cases, 
wait  until  all  patience  as  well  as  pulsation  had  ceased  ;  for  example,  La  Motte4 
mentions  going  to  a  woman  who  had  been  delivered  trois  grosses  heures  before  his 
arrival ;  the  child  was  lying  between  the  mother's  thighs,  the  placenta  un- 
delivered, and  "  the  beating  of  the  cord  was  of  a  marvellous  force." 

It  is  not  necessary  nor  advisable  to  make  an  absolute  rule  that  pulsa- 
tion must  cease  before  tying ;  when  the  child  cries  vigorously,  breathes 
freely,  and  the  pulsation  lessens  in  force,  one  usually  need  not  wait. 

Various  material  has  been  used  for  tying  the  cord.  The  late  Dr. 
Bedford  preferred  tape,  believing  that  if  a  round  string  was  used  the 
child  was  more  liable  to  trismus.  Dickson5  first  advised  the  elastic 
ligature,  and  Tarnier  uses  it  in  addition  to  the  ordinary  one.  A  few 
strands  of  hemp  thread  answer  the  purpose  very  well ;  but  my  prefer- 
ence is  for  the  Chinese  silk  used  in  tying  the  pedicle  in  ovariotomy,  for 
it  is  strong,  and  a  tight  knot  can  be  made  without  any  danger  of  either 
cutting  the  cord  or  the  obstetrician's  fingers.  Whatever  is  used,  it  ought 
not  to  be  so  thin  as  to  risk  cutting  the  cord,  or  cutting  the  physician's 
fingers  when  he  is  drawing  the  knot.  The  ligature  is  placed  about 
three  fingers'  breadth  from  the  umbilicus;  the  string  or  tape  is  passed 
under  the  cord,  the  ends  brought  above  and  tied,  gradually  and  firmly 
compressing  the  cord  so  as  to  force  away  at  the  place  of  constriction 
the  gelatinous  portion,  with  a  surgeon's  knot  and  then  a  single  knot.6  In 

i  Obstetrique  et  Gynecologic,  Paris,  1886.  *  Centralblatt  fur  Gynakol.,  1885. 

3  Gazet.  deg.  Hosp.,  1892. 

4  Observation  ccxxx. 

6  Proceedings  of  Edinburgh  Obstetrical  Society,  January  14, 1874. 

6  It  is  generally  recommended  that  a  second  ligation  of  the  cord  be  made,  partly  upon  the 
ground  that  thereby  the  clothing  is  protected  from  the  soiling  caused  by  escape  of  blood  from  the 
placental  end  of  the  funis,  and  chiefly  because  it  was  believed  that  if  this  escaping  blood  was 
retained  in  the  placenta,  the  detachment  of  the  latter  occurred  more  promptly.  But  Budin  and 


THE  CONDUCT  OF  LABOR.  309 

plural  pregnancy  a  second  ligature  is  required  because  of  the  possible 
vascular  connection  between  the  circulation  of  the  two  foetuses  in  the 
placenta.  After  ligation  the  cord  is  divided,  care  being  taken  to  leave 
a  large  button-like  projection  at  the  foetal  portion,  so  that  the  ligature 
cannot  slip  off;  blunt-ended  scissors  are  best  for  making  this  section, 
and  the  obstetrician  must  be  watchful  lest  a  finger  or  some  other  part  of 
the  foetus  be  included  with  the  cord  between  the  blades.  After  the  sec- 
tion press  a  soft  rag  upon  the  cut  surface  to  dry  it,  and  then  watch  for 
a  minute  or  two  to  see  if  there  be  any  oozing  of  blood ;  if  there  be, 
another  ligature  must  be  immediately  applied. 

The  obstetrician  now  hands  the  child  to  the  nurse,  who  has  a  small 
blanket  or  shawl,  which  has  been  warmed  for  its  reception.  In  hand- 
ing it  to  her  he  either  places  the  right  hand  under  the  shoulders,  the 
thumb  and  index  finger  supporting  the  head,  and  the  left  hand  holding 
the  ankles ;  or,  as  taught  by  Dr.  Hodge,  he  embraces  the  thorax  of  the 
infant  with  the  right  hand  extended  so  that  the  palm  is  over  the  ster- 
num, the  thumb  under  the  right  axilla,  and  the  fingers  under  the  left, 
and  the  head  falls  toward  the  sternum  ;  this  is  a  natural  position  for  the 
child,  the  practitioner  has  a  firm  hold,  and  the  left  hand  is  left  free  for 
any  required  assistance.  Trivial  as  these  directions  may  seem  to  the 
student,  yet  in  practice  he  will  find  that  attention  to  the  little  things  has 
much  to  do  with  the  obstetrician's  success. 

WASHING  THE  CHILD  AND  DRESSING  THE  CORD.  Though  wash- 
ing the  infant  and  dressing  the  cord  are  usually  done  by  the  nurse,  yet 
occasionally  one  or  both  of  these  duties  may  devolve  upon  the  doctor, 
and  even  if  this  be  not  the  case,  he  ought  to  know  how  they  are  best 
done.  There  are  needed  for  the  washing  a  soft  sponge,  a  piece  of  old 
linen  or  cotton  cloth,  water  at  a  temperature  of  100°  F.,  some  oily  sub- 
stance, such  as  unsalted  butter,  lard,  sweet  oil,  or  vaseline — or,  instead 
of  any  of  these,  the  yelk  of  a  fresh  egg — and  Castile  or  some  one  of 
the  finer  soaps ;  transparent  glycerin  soap  is  good.  The  oily  matter,  or 
the  egg-yelk,  is  used  for  the  purpose  of  facilitating  the  removal  of  the 
vernix  caseosa,  and  the  body  of  the  child  is  first  rubbed  with  one  of 
these  substances.  The  face  is  now  washed  with  warm  water  simply,  no 
soap  being  used,  lest  some  of  t"he  soapy  water  should  get  into  the  infant's 
eyes,  causing  pain,  and  possibly  a  conjunctival  irritation  which  may 
result  in  inflammation ;  children  of  a  larger  growth  will  strenuously 
object  to  soap-water  for  washing  their  eyes,  and  let  the  infant  be  treated 
as  kindly.  After  washing  and  drying  the  face,  the  body  and  limbs  are 
washed  with  soap  and  water,  and  well  dried ;  the  washing  of  course 
must  be  done  in  a  warm  room,  quickly,  avoiding  prolonged  or  unneces- 
sary exposure  of  the  child,  and  with  gentleness,  care  being  taken  not  to 
irritate  the  sensitive  skin  by  rude  rubbing,  even  though  some  portion  of 
the  vernix  caseosa  may  remain,  for  it  will  dry  up  in  a  day  or  two,  and 
be  spontaneously  detached,  or  can  be  removed  at  a  subsequent  washing. 
After  drying  the  infant,  powdered  starch  is  dusted  over  the  surface,  espe- 
cially at  the  flexures  of  the  knees,  thighs,  and  elbows,  and  in  the  axillae. 

Ribemont-Dessaignes  have  experimentally  proved  that  the  blood  escaping  from  the  placental  end 
of  the  cord,  in  lessening  the  volume  of  the  placenta,  facilitates  its  separation,  permitting  uterine 
retraction  which  little  by  little  reduces  the  surface  of  placental  attachment.  Unless,  then,  in  cases 
of  plural  pregnancy  a  single  ligation  is  advisable. 


310  PHYSIOLOGY  OF  LABOR. 

If  the  mother  has  had  a  purulent  vaginal  discharge,  even  if  there  is 
any  suspicion  of  her  having  had  a  specific  vaginitis,  the  child's  eyes 
having  been  first  carefully  washed  with  warm  water,  should  have  ap- 
plied to  them  a  drop  or  two  of  a  2-g-rain  solution  of  nitrate  of  silver. 

The  common  method  of  dressing  the  cord  is  this  :  A  square  piece  of 
old  linen,  a  little  more  than  twice  the  length  of  the  attached  cord,  is 
slightly  scorched,  a  hole  cut  in  its  centre,  and  mutton  suet  put  upon  its 
under  surface;  the  cord  is  passed  through  the  hole,  then  the  linen  folded 
first  transversely,  and  afterward  from  side  to  side,  over  the  cord  so  that 
the  latter  is  completely  wrapped.  lodoform  or  creolin  gauze  may  be 
used  for  wrapping  the  cord,  absorbent  cotton  or  cotton-wool  is  objection- 
able because  the  drying  of  the  cord  cannot,  when  thus  covered,  occur  so 
readily.  Goodell  advised  squeezing  out  Wharton's  jelly  from  the  cord, 
and  this  certainly  seems  to  me  best.  When  the  duty  of  caring  for  the 
cord  devolves  upon  the  practitioner,  he  may  pursue  the  following  plan  : 
Let  him  take  a  piece  of  soft  cotton  rag,  place  it  upon  the  cord,  and  grasp 
the  latter  just  below  where  it  has  been  tied  with  the  thumb  and  fingers 
of  the  left  hand  ;  now  cut  off  the  cord  at  the  point  of  ligation,  and  then 
squeeze  out  all  of  Wharton's  jelly  upon  the  rag,  and  in  a  minute  or  two 
the  cord  is  reduced  to  half  its  former  size,  and,  instead  of  being  a  solid 
cylinder,  is  a  limp,  ribbon-like  body.  A  new  ligature  is  now  applied, 
and  bleeding  is  impossible.  A  little  iodoform,  or  a  powder  of  starch 
and  salicylic  acid,  may  be  sprinkled  upon  the  stump  of  the  cord,  and 
then  it  may  be  encircled  with  a  few  turns  of  a  linen  or  muslin  bandage, 
an  inch  to  an  inch  and  a  half  in  width,  which  is  fastened  by  a  silk 
or  hemp  thread ;  no  subsequent  dressing  is  needed ;  the  cord  and 
bandage  will  fall  off  together  in  a  few  days.  The  advantages  of  this 
plan  are  the  comfort  of  the  child,  absolute  security  from  hemorrhage, 
and  the  lessened  mass  to  be  detached. 

DRESSING  THE  CHILD.  The  "  belly-band,"  which  is  almost  uni- 
versally used,  should  not  be  tight,  for  the  increase  in  pulmonary  capac- 
ity in  the  newborn  is  chiefly  due  to  descent  of  the  diaphragm,  and  the 
bandage  must  be  sufficiently  loose  to  permit  this  increase ;  a  bandage 
that  is  loose  immediately  after  birth  may  often  after  a  few  hours  cause 
injurious  compression ;  it  will  be  the  duty  of  the  obstetrician  to  see 
that  no  mistake  is  made  in  this  matter.  The  fewer  pins  used  in  fasten- 
ing the  clothing  of  the  infant  the  better,  and  as  far  as  possible  tapes 
should  replace  them. 

APPARENT  DEATH  OF  THE  NEWBORN.  The  child  born  apparently 
dead  does  not  cry,  does  not  breathe,  or  only  at  long  intervals  gives  a 
faint  gasp,  there  is  absence  of  reflex  movements,  but  pulsations  of  the 
heart  still  occur,  though  they  are  very  weak.  The  most  frequent  cause 
is  asphyxia,  and  this  asphyxia  may  result  from  compression  of  the 
cord,  for  example,  in  prolapse,  or  from  coils  about  the  child's  body,  or 
in  head- last  labor  Further,  the  asphyxia  may  be  caused  by  premature 
separation  of  the  placenta,  or  from  continuous  uterine  contraction,  or 
from  the  mother's  blood  failing  to  furnish  oxygen  to  that  of  the  child, 
as  in  grave  hemorrhage,  eclampsia,  and  various  diseases  which  cause 
accumulation  of  carbonic  acid  in  her  blood.  The  child  in  utero  threat- 
ened with  apparent  death  may  have  a  discharge  of  meconium,  and  the 


THE  CONDUCT  OF  LABOR.  311 

discovery  of  this  excretion  in  the  amnial  liquor  during  labor  when  the 
pelvis  does  not  present  justly  awakens  suspicion  of  peril,  though  fre- 
quently this  accident  occurs  and  birth  of  a  perfectly  healthy  child  fol- 
lows. More  important  is  the  condition  of  the  pulsations  of  the  foetal 
heart  as  indicating  asphyxia ;  these  either  are  greatly  increased  in  fre- 
quency or  fall  below  the  normal — in  each  case  they  become  feeble,  less 
distinct.  The  failure  of  placental  respiration,  the  foetus  being  thus  threat- 
ened with  asphyxia,  causes  in  many  cases  the  effort  at  pulmonary  respira- 
tion, and  hence  there  may  be  drawn  into  the  air-passages  amnial  liquor, 
mucus,  blood,  etc.,  aggravating  the  original  affection  and  making  the 
treatment  more  difficult.  In  apparent  death  from  asphyxia  the  color  is 
almost  purple  ;  the  features,  especially  the  lips,  swelled ;  the  cord  is 
large  and  full  of  blood ;  the  limbs  are  not  flaccid,  but  even  may  be 
somewhat  rigid.  It  has  been  described  as  blue  asphyxia,  and  some- 
times, too,  spoken  of  as  apoplectic.  A  rarer  form  of  failure  of  respi- 
ration in  the  newborn  has  been  called  pale  asphyxia.  The  child's  sur- 
face is  remarkably  white  ;  the  limbs  limp  and  relaxed;  the  cord  small, 
thin,  apparently  almost  bloodless.  The  condition  is  very  much  more 
unfavorable  than  that  previously  described.  It  has  been  called  syn- 
cope, and  probably  that  is  the  best  designation.  Its  origin  seems  to  be 
most  frequently  pressure  upon  the  brain,  and  is  oftenest  observed  after 
labor  in  case  of  a  contracted  pelvis,  or  after  the  application  of  the  for- 
ceps ;  intra-cranial  hemorrhage  may  be  present  instead  of  hypersemia, 
and  then  recovery,  if  recovery  occurs,  is  very  slow.  Depaul  has  spoken 
of  pale  asphyxia  occurring  in  premature  birth,  and  also  in  case  of  want 
of  nourishment  from  disease  of  the  placenta,  for  certain  changes  in  this 
organ  may  produce  a  progressive  inanition  which  does  not  kill,  but  the 
child  is  born  thin,  emaciated,  and  feeble. 

TREATMENT.  Division  of  the  cord  is  made  at  once,  but  in  pale 
asphyxia  Depaul  advises  pressing  toward  the  child's  body  all  the  even 
scanty  supply  of  blood  in  the  cord  before  cutting  it ;  and  it  has  been 
the  custom  in  blue  asphyxia  to  let  a  teaspoonful  of  blood  escape  from 
the  foetal  end  before  ligating,  though  now  most  authorities  assert  this 
is  useless.  I  have  often  done  it,  still  do  it,  and  am  glad  to  find  that 
Winckel  approves  the  practice.  Immediately  after  separating  the 
child  from  the  mother  the  mouth  and  fauces  are  cleansed  of  mucus  by 
means  of  the  little  finger  wrapped  with  mull,  and  also  the  nares  with 
a  feather  (Ahlfeld).  It  may  then  be  put  in  a  hot  bath,  and  while  lying 
supported  by  the  obstetrician  a  little  cold  water  thrown  upon  the  ex- 
posed breast.  If  respiration  still  fails  to  be  made  after -two  or  three 
minutes,  other  means  must  be  employed.  Faradization  of  the  phrenic 
nerves  has  been  successful,  but  the  means  for  employing  this  are  rarely 
at  hand.  Artificial  respiration  comes  next.  The  readiest  way  of  effect- 
ing this  is  by  the  Sylvester  method  :  The  infant  has  hot,  dry  flannel 
applied  to  it,  is  placed  upon  its  back,  the  head  slightly  raised  by  a  small 
pillow,  then  the  arms  are  raised  and  brought  by  the  sides  of  the 
child's  head,  then  to  the  sides  of  the  child's  chest ;  these  alternate 
movements — one  promoting  inspiration,  the  other  expiration — are  con- 
tinued for  a  fewT  minutes.  The  removal  of  mucus  from  the  air-passages 
is  in  some  cases  of  essential  importance.  This  removal  may  be  effected 


312  PHYSIOLOGY  OF  LABOR. 

by  the  position  of  the  child,  as  will  be  explained  in  describing  Schultze's 
method  of  resuscitation,  by  introducing  a  flexible  rubber  catheter  in  the 
trachea  and  sucking  out  fluids,  or  by  means  of  Ribemont-Dessaigues' 
instrument,  probably  the  best  of  aspirators  and  insufflators ;  the  laryn- 
geal  tube  of  Depaul  may  be  used  in  a  similar  manner  to  that  of  the 
rubber  catheter.  The  instrument  of  Ribemont-Dessaignes  consists  of 
a  laryngeal  tube  and  of  a  pear-shaped  rubber  bulb,  readily  attached 
and  removed  from  the  tube.  To  introduce  the  tube,  let  the  child  be 

FIG.  137. 


INSUFFLATOK  OF  RlBEMONT  DESSAIGNES . 

upon  the  back,  its  head  supported  by  a  pillow ;  the  index  finger  is 
introduced  in  the  child's  mouth  and  directed  so  that  its  pulp  touches 
the  arytenoid  cartilages,  and  then  the  tube  is  guided  by  it  into  the 
larynx ;  thence  it  is  gently  buried  in  the  trachea  and  brought  to  the 
median  line.  For  the  removal  of  secretions  that  have  entered  the  air- 
passages,  let  the  compressed  bulb  be  applied  to  the  tube,  and  upon 
removing  the  compression  the  fluids  are  promptly  aspirated.  Remove 
the  bulb,  and,  having  its  opening  dependent,  press  it  so  that  everything 
escapes  from  it.  Next  filled  with  air,  it  is  applied  to  the  tube,  and 
gentle  compression  drives  this  air  into  the  lungs.  The  insufflations 
may  be  practised  once  in  eight  or  ten  seconds.  If  respiratory  move- 
ments are  made,  the  period  intervening  between  insufflations  is  length- 
ened. Artificial  respiration  should  be  employed  as  long  as  the  heart 
continues  to  beat.  Ribemont-Dessaignes,  after  describing  his  instru- 
ment and  its  application,  says  that  it  is  sometimes  not  until  the  end  of 
half  an  hour,  or  even  three-quarters,  that  the  infant  makes  the  first 
respiratory  movements,  and  it  may  not  be  until  the  end  of  an  hour  or 
more  it  first  cries. 

French  obstetricians  are  partial  to  the  means  previously  mentioned, 
while  by  most  German  authorities  "Schultze's  swinging"  is  generally 
regarded  as  the  most  valuable  means  of  resuscitation.  This  is  done  as 
follows:  The  operator  stands  with  his  lower  limbs  somewhat  widely 
apart,  and  his  body  slightly  inclined  forward,  the  arms  and  forearms 
extended.  The  infant  is  now  held,  its  anterior  plane  in  front,  by  the 
index  finger  of  each  hand  entering  the  axilla?  from  behind,  thumbs 
supporting  the  face  laterally,  and  their  ends  resting  upon  the  upper  and 
anterior  part  of  the  thorax.  This  is  the  position  of  inspiration.  After 
a  moment  the  operator  very  quickly  raises  his  arms  until  they  pass  the 
horizontal  line  and  become  oblique  with  reference  to  his  body,  and  the 
child  is  made  to  revolve  upon  the  index  fingers  as  an  axis,  so  that  its 


THE  CONDUCT  OF  LABOR.  313 

head  is  now  lowest,  and  its  hips  highest,  its  lower  limbs  falling  upon  the 
anterior  aspect  of  the  body  which  is  directly  before  the  operator's  face ; 
the  child's  weight  in  this  position  rests  upon  his  thumbs,  which  are 
placed  upon  the  anterior  face  of  the  thorax.  If  this  movement  of  par- 
tial revolution  be  made  too  rapidly,  the  child's  back  is  bent  too  much 
in  the  dorsal  vertebrae,  whereas  it  is  designed  the  bending  shall  occur 
in  the  lumbar  vertebrae.  While  the  head  is  in  the  dependent  position 
the  movement  of  expiration  occurs,  and  any  fluids  that  may  have  entered 
the  air-passages  flow  out.  The  operator  now  lowers  his  arms,  swing- 
ing the  child  back  into  the  first  position,  when  all  pressure  of  the  thumbs 
upon  the  chest  is  relaxed  so  that  they  may  give  no  impediment  to  inspi- 
ration. These  movements  are  repeated  at  suitable  intervals. 

Ahlfeld,  after  mentioning  several  accidents  that  have  occurred  from  the 
"swinging,"  such  as  pulmonary  hemorrhage,  hemorrhage  in  the  supra-renal 
capsules  and  into  the  abdominal  cavity,  rupture  of  the  liver  and  of  an  enlarged 
spleen,  fracture  of  the  ribs,  states  that  the  method  is  not  to  be  recommended 
for  employment  by  the  unskilled,  consequently  by  most  midwives. 

In  Forrest's  method1  of  artificial  respiration  the  child,  after  being  turned  upon 
its  abdomen,  the  head  lower  than  the  pelvis,  and  pressure  made  upon  the  back 
to  cause  escape  of  any  fluid  that  has  entered  the  mouth  and  trachea,  is  placed  in 
a  sitting  position  in  a  bucket  half- full  of  hot  water,  "the  water  being  just  above 
the  infant's  heart."  The  arms  of  the  child  are  carried  upward  and  a  little  back- 
ward by  the  operator's  left  hand,  until  the  weight  of  the  body  comes  upon  the 
shoulders.  The  operator  takes  an  inspiration  bending  forward,  applies  his 
mouth  to  that  of  the  child,  and  "blows  the  air  directly  in  the  lungs."  Expira- 
tion is  made  by  doubling  the  child's  body  forward  upon  itself,  its  arms  brought 
to  the  sides,  and  pressure  downward  and  backward  made  upon  the  chest  ante- 
riorly. Dr.  Forrest  states  that  "  artificial  respiratory  movements  should  be  made 
at  the  rate  of  forty  per  minute,  instead  of  twenty,  as  usually  taught." 

Winckel  says  that  this  method  is  "not  sufficiently  energetic  for  severe  cases." 
Moreover,  it  is  amenable  to  the  just  objection  to  all  modes  of  mouth-to-mouth 
insufflation,  that  it  is  probable  tuberculous  disease  may  thereby  be  communi- 
cated, as  the  facts  of  Reich,  quoted  by  Kaltenbach,  go  far  toward  showing. 
Directly  breathing  into  an  infant's  lungs  ought  not  to  be  admitted  as  a  common 
way  of  resuscitation. 

Dew's2  method  is  this :  "  Grasp  the  infant  with  the  left  hand,  allowing  the 
neck  to  rest  between  the  thumb  and  forefinger,  the  head  falling  over  backward, 
straightening  the  mouth  with  the  larynx  and  trachea,  thereby  serving  to  raise 
and  hold  open  the  epiglottis ;  the  upper  portion  of  the  back  and  the  scapulae 
resting  in  the  palm  of  the  hand,  the  other  three  fingers  to  be  inserted  in  the 
axilla  of  the  baby's  left  arm,  raising  it  upward  and  outward. 

"  Then,  with  the  right  hand,  if  the  baby  is  large  and  heavy,  grasp  the  knees  in 
such  a  way  as  to  hold  them  with  the  right  knee  resting  between  the  thumb  and 
forefinger,  the  left  between  the  fore  and  middle  fingers.  This  position  will  allow 
the  back  and  the  thighs  to  rest  in  the  palm  of  the  operator's  hand.  If  the 
infant  is  small  and  light,  it  will  be  found  more  convenient  and  easier  to  hold  it 
in  the  same  way  by  the  ankles  instead  of  the  knees,  allowing  the  calves  instead 
of  the  thighs  to  rest  in  the  palm  of  the  hand. 

"  The  next  step  is  to  depress  the  pelvis  and  lower  extremities,  so  as  to  allow  the 
abdominal  organs  to  drag  the  diaphragm  downward,  and  with  the  left  hand  to 
bend  gently  the  dorsal  region  of  the  spine  backward.  This  enlarges  the  thoracic 
cavity  and  produces  inspiration. 

"  Then,  to  excite  expiration,  reverse  the  movement,  bringing  the  head,  shoulders, 
and  chest  forward,  closing  the  ribs  upon  each  other,  and  at  the  same  moment 
bring  forward  the  thighs,  resting,  them  upon  the  abdomen.  This  movement 
arches  the  lumbar  region  backward,  and  so  bends  the  child  upon  itself  as  to 

1  New  York  Medical  Record,  1892. 

2  New  York  Medical  Record,  March,  1893. 


314  PHYSIOLOGY  OF  LABOR. 

crowd  together  the  contents  of  the  thoracic  and  abdominal  cavities,  resulting  in 
a  most  complete  and  forcible  expiration.  While  this  movement  is  a  powerful 
one,  the  operator  can,  by  his  manipulations,  accomplish  it  without  shock  and 
render  it  as  gentle  as  he  pleases." 

ATTENTIONS  TO  THE  MOTHER.  Immediately  after  the  birth  of  the 
child  the  mother  is  placed  upon  her  back,  if  she  was  delivered  lying 
upon  her  side,  with  but  a  single  pillow,  or  only  the  bolster  under  her 
head.  From  the  time  of  the  birth  the  hand  of  the  assistant,  which  was 
placed  upon  the  uterus,  following  it  down  during  the  expulsion  of  the 
child,  is  kept  there  until  replaced  by  that  of  the  obstetrician.  It  must 
be  borne  in  mind  that  the  hand  is  applied,  not  flat,  but  with  the  fingers 
and  thumb  so  flexed  that  a  concave  surface  is  formed  corresponding 
with  the  convexity  of  the  uterus,  and  that  the  purpose  of  this  normal 
application  is  to  assist  uniform  uterine  retraction,  thus  securing  early 
delivery  of  the  placenta,  and  guarding  against  hemorrhage.  It  is  the 
custom  of  some  practitioners  to  administer  from  a  half  to  a  teaspoonful 
of  fluid  extract  of  ergot  immediately  after  the  birth  of  the  child,  while 
others  defer  it  until  after  the  delivery  of  the  placenta,  and  still  others 
omit  its  use  altogether  in  physiological  conditions.  Ergot  given  after 
the  removal  of  the  placenta  probably  cannot  interfere  in  any  way  with 
normal  processes ;  it  certainly  is  one  of  the  most  important  means  in 
prophylaxis  of  post-partum  hemorrhage,  and  possibly  it  assists  uterine 
involution.  But  unless  there  are  plain  indications,  it  is  better  to  omit  it. 

PLACENTAL  EXPULSION.  The  delivery  of  the  placenta  is  one  of 
the  most  important  of  the  accoucheur's  duties.  The  patient  is  anxious 
until  this  final  act  in  the  drama  ends;  she  cannot  have  the  soiled  clothes 
removed  from  her  person  and  from  the  bed,  nor  parts  that  have  been 
bruised  bathed,  nor  secure  that  repose  which  her  exhausted  condition 
needs;  a  delay  is  sometimes  the  source  of  fear  to  her  at  least,  according 
to  the  popular  expression,  that  "the  after-birth  has  grown  fast  to  her 
side."  Therefore  it  is  unwise,  so  far  as  her  immediate  comfort  is  con- 
cerned, to  do  as  practitioners  in  ancient  times  did,  leave  the  delivery  of 
the  placenta  to  nature,  pursuing  a  merely  expectant  treatment.  The 
time  of  the  practitioner  also  gives  an  argument  against  expectation.  He 
canuot  wait  hours  at  the  bedside,  as  would  be  necessary  in  some  cases 
for  nature  to  expel  the  placenta,  when  a  little  manipulation  on  his  part, 
simply  assisting  nature,  will  accomplish  this  delivery  in  a  few  minutes. 
The  following  table  of  100  cases  in  which  the  delivery  of  the  placenta 
was  left  to  nature  is  given  by  Kabierske  :l 

24  times  30  minutes.  5  times       .  .5  hours. 
20     "                        1  hour.                                   3     "                          .    6     " 

25  "  2  hours.  2     "  .    8     " 
11     "                       3     "                                    1  time        .       .       .  12     " 

9     "  4     " 

These  figures  are  conclusive  against  trusting  to  purely  spontaneous 
delivery  of  the  placenta.  The  method  more  or  less  closely  followed  by 
most  obstetricians  is  known  as  that  of  Credo",  and  briefly  stated  is  this : 
Frictions,  at  first  gentle  and  then  more  or  less  vigorous,  of  the  fund  us 
and  of  the  body  of  the  uterus  are  made  through  the  abdominal  wall. 
When  a  uterine  contraction  occurs  the  obstetrician  applies  his  hand  to 

i  Centralblatt  fur  Gynakol.,  1881. 


THE  CONDUCT  OF  LABOR.  315 

the  organ,  the  palm  upon  the  fundus,  the  four  fingers  upon  the  poste- 
rior and  the  thumb  upon  the  anterior  \\all,  and  exerts  a  moderate  pres- 
sure, which  is  soon  followed  by  the  expulsion  of  the  placenta — it  is 
thus  expressed,  squeezed  out  "  as  the  seed  from  a  ripe  cherry  compressed 
between  the  thumb  and  fingers."  It  is  necessary  in  some  cases  to  re- 
peat this  manipulation  once  or  ofteuer  before  successful.  Crede's  method 
has  not  escaped  criticism.  Riol1  justly  states  that  if  practised  with  too 
much  rapidity  and  energy,  and  immediately  after  the  delivery  of  the 
foatus,  it  may  cause  tearing  the  membranes  and  retention  of  fragments. 
It  would  be  better  in  physiological  cases  not  to  hurry  uterine  action  by 
friction,  but  simply  to  keep  the  hand  applied  to  the  uterus,  as  first 
directed,  acting  in  the  beginning  as  a  sentinel  to  warn  of  danger  and 
advise  of  condition,  and  then  as  an  ally  of  uterine  contractions  when 
they  normally  occur,  a  reinforcement  to  uterine  power,  not  usurping  its 
place,  but  simply  assisting  it.  Delivery  of  the  placenta  by  expression 
is  certainly  preferable  to  that  by  traction  ;  it  is  nature's  way  to  have 
the  deliverance  made  by  a  vis  a  tergo,  not  by  a  vis  afronte,  and  untimely 
pulling  upon  the  cord  can  cause  inversion  of  the  uterus,  or  serious 
hemorrhage.  But  granting  all  this,  haste  and  great  force  in  expression 
are  an  evil ;  Nature  should  be  the  guide,  give  the  signal  for  action,  and 
art  be  the  follower  and  servant. 

Pajot  advises,  after  grasping  the  cord,  at  first  to  exercise  a  prolonged  tension 
during  some  minutes,  and  subsequently  moderate  tractions  in  the  pelvic  axis. 
Ribemont-Dessaignes2  claims  that  this  tension  is  as  rational  in  principle  as  it  is 
fortunate  in  results.  Pajot's  method,  instead  of  trying  to  increase  the  size  of 
the  uterine  orifice,  seeks  to  reduce  the  volume  of  the  placenta ;  and  this  reduction, 
favored  by  the  special  structure  of  the  organ,  is  easily  obtained  if  the  latter  is 
permitted  to  mould  itself  little  by  little  to  the  passage  it  must  traverse — in  a 
word,  to  accommodate  itself. 

"  No  teaching  as  to  the  delivery  of  the  placenta  can  be  scientific  which  does 
not  direct  attention  to  the  character  of  the  preceding  labor  ;  and  as  the  character 
of  labors  varies,  so  must  the  management  of  the  third  stage.  If  the  pains  have 
been  frequent  and  energetic,  and  the  birth  of  the  child  rapid,  the  placenta  may 
be  delivered  very  soon ;  if  the  labor  has  been  tedious  and  the  delivery  slow,  or 
if  the  uterus  has  been  exhausted  by  long  continuous  effort,  time  must  be  given 
for  the  recuperation  of  its  contractile  force  and  nervous  energy."3 

It  is  generally  advised  that  in  removing  the  placenta  from  the  vagina 
the  former  should  be  rotated  so  as  to  twist  the  membranes  into  a  rope, 
as  it  is  supposed  there  is  then  less  danger  of  their  tearing  and  fragments 
being  left  behind.  Such  an  accident  is  not  likely  to  happen  if  they 
have  been  completely  detached  from  the  uterus,  and  the  manoeuvre  is 
hardly  necessary,  simple,  gradual  withdrawal  being  sufficient.  When 
removed,  the  placenta  and  membranes  are  put  in  a  vessel  brought  by 
the  nurse,  which  should  be  turned  upon  its  side,  and  put  with  its  rim 
as  near  the  vulva  as  possible,  so  that  they  can  be  slid  in  rather  than 
lifted,  thus  avoiding,  as  far  as  possible,  soiling  the  clothes  or  the  person 
of  the  patient.  After  this  the  obstetrician  removes  clots  that  may  be  in 
the  bed,  and  puts  them  into  the  vessel,  when  it  is  taken  away,  but  kept 

1  Etude  Critique  et  Clinique  de  la  Deliverance  par  Expression. 

2  De  la  Deliverance  par  Traction  et  par  Expression.    Paris,  1883. 

3  Reeve  :  Transactions  of  the  Ohio  State  Medical  Society,  1884. 


316  PHYSIOLOGY  OF  LABOR. 

uneraptied  until  he  has  an  opportunity  to  examine  the  uterine  surface 
of  the  placenta,  and  be  sure  that  no  fragments  have  been  left  in  the 
uterine  cavity.  Before  removing  the  hand  which  has  been  applied  to 
the  uterus  through  the  abdominal  wall,  the  size,  position,  and  firmness 
of  the  uterine  globe  should  be  found  to  be  normal. 

APPLICATION  OF  THE  BANDAGE.  After  the  removal  of  soiled 
clothes  the  abdominal  bandage  may  be  applied.  The  value  of  this  has 
often  been  disputed,  nevertheless  most  patients  think  themselves  more 
comfortable  with  it,  and  desire  it  to  be  used  ;  indeed,  some  are  not 
satisfied  unless  their  professional  attendant  applies  it. 

Confirmation  of  the  value  of  the  abdominal  bandage  has  recently 
been  given  by  Prochowuick.1  It  should  be  worn  not  merely  while 
lying  in  bed,  but  for  some  time  after  beginning  to  sit  up.  Usually  a 
bandage  made  for  the  occasion  is  at  hand  ;  but  if  not,  a  bolster  cover, 
as  suggested  by  Leishman,  or,  better  than  it,  a  moderately  coarse  crash 
towel  may  be  used.  The  bandage  is  rolled  one-half  its  length,  and  the 
roll  carried  under  the  patient's  back  to  the  opposite  side,  when  it  is 
unrolled,  drawn  so  as  to  be  smooth,  and  arranged  to  extend  from  the 
chest  somewhat  over  the  hips.  It  is  then  pinned  as  tightly  as  is  com- 
fortable, the  pinning  being  begun,  as  taught  by  Warrington,2  above, 
though  of  course  this  is  not  very  material.  To  prevent  the  bandage 
from  slipping  a  layer  of  cotton  wadding  may  be  placed  upon  the  abdo- 
men, if  the  weather  be  not  so  warm  that  this  addition  will  cause  dis- 
comfort. Some  place  a  pad,  formed  of  one  or  more  folded  napkins, 
upon  the  abdomen  before  the  bandage  is  fastened,  for  the  purpose  of 
producing  compression  of  the  uterus  :  if  small,  it  does  neither  good  nor 
harm;  but  if  thick,  it  may  press  the  uterus  out  of  place.  A  better 
plan  of  securing  uterine  compression,  should  this  be  thought  necessary, 
is  the  following  :  Make  three  firm  rolls  rather  thicker  than  the  wrist, 
of  as  many  towels ;  then  place  one  of  them  transversely  just  above  the 
uterus,  and  the  other  two  at  its  sides,  and  let  the  bandage  be  pinned 
firmly  over  them ;  thus  the  uterus  is  as  it  were  included  in  a  box,  the 
lid  of  the  box  being  the  portion  of  the  bandage  in  front  of  the  abdo- 
men. 

A  warm  vaginal  injection  of  a  3  per  cent,  solution  of  carbolic  acid,  or 
a  1 J  per  cent,  solution  of  lysol,  or  a  teaspoonful  of  creolin  to  a  quart  of 
water,  may  be  used,  and  with  this  solution  the  external  sexual  organs 
and  adjacent  parts  are  washed. 

If  there  be  the  slightest  suspicion  of  any  injury  to  vulva  or  peri- 
neum, it  is  the  duty  of  the  obstetrician  to  make  a  careful  inspection  of 
the  parts  after  the  washing.  As  a  rule,  should  there  be  any  serious 
tear  of  the  perineum  sutures  must  be  at  once  introduced.  Slight  tears 
there  or  elsewhere  may  be  'covered  with  an  antiseptic  powder,  as  of 
iodoform.  Then  an  antiseptic  napkin  or  pad  is  applied  to  the  vulva, 
the  chemise  and  night-dress  drawn  down,  and  the  patient  prepared  for 
that  rest  which  her  exhausted  state  so  much  needs. 

Dr.  Fullerton,  in  her  excellent  work  upon  Obstetrical  Nursing,  gives  the  follow- 
ing description  of  the  antiseptic  dressings  used  in  the  Woman's  Hospital,  Phila- 

1  Op.  cit.  2  Obstetric  Catechism. 


THE  CONDUCT  OF  LABOR.  317 

delphia :  "  They  consist  of  a  piece  of  dry  patent  lint,  six  by  eight  inches,  which 
has  previously  been  rendered  antiseptic  by  saturation  in  a  solution  of  bichloride 
of  mercury  1 : 1000.  This  is  placed,  doubled  in  its  width,  so  as  to  make  a  dress- 
ing three  by  eight  inches,  directly  over  the  external  organs  of  generation. 
This  lint  is  covered  by  a  piece  of  gutta-percha  tissue,  four  by  nine  inches,  which 
is  wet  in  a  1 : 4000  solution  of  bichloride  of  mercury.  These  dressings  are  kept 
in  place  by  a  napkin  of  sublimated  cheese-cloth,  eighteen  inches  square,  folded 
to  form  a  diagonal  five  inches  in  width,  within  whose  folds  a  pad  of  oakum  is 
enclosed.  The  napkin  is  tightly  fastened  to  the  abdominal  bandage,  both  ante- 
riorly and  posteriorly,  by  means  of  safety-pins,  and  the  access  of  air  to  the 
vagina  is  thus  prevented.  These  dressings  are  changed  at  least  once  in  three 
hours,  the  dressing  removed  being  at  once  burned.  It  is  seldom  necessary  to 
continue  the  dressings  longer  than  two  weeks." 

In  my  own  practice  I  direct,  instead  of  this  "  occlusive  dressing,"  simply  a  pad 
of  absorbent  cotton  that  has  been  dipped  in  a  3  per  cent,  mixture  of  creolin  and 
water,  and  dried ;  this  pad  will  be  retained  without  the  napkin  if  placed  between 
the  thighs  closely  upon  the  external  genitals,  or  the  napkin  may  enclose  it,  and 
be  fastened  in  front  and  behind  to  the  abdominal  bandage.  Of  course,  the  pad 
will  be  removed  as  soon  as  soiled,  a  fresh  one  applied,  the  old  one  burned. 
Winckel  advises  a  pad  of  salicylated  cotton,  and  Auvard  says  that  "  it  is  the 
best  and  most  simple  barrier  against  the  entrance  of  microbes." 

Kaltenbach  directs  the  application  of  sterilized  cotton  or  jute  to  the  genitals. 

The  practitioner  remains  with  the  patient  for  an  hour  after  the  labor 
has  ended,  and  then,  if  she  be  comparatively  free  from  suffering,  the 
uterus  well  contracted,  and  the  pulse  and  flow  normal,  he  need  not 
hesitate  to  leave. 

The  woman  is  now,  in  the  strict  sense  of  the  term,  a  puerpera,  and 
the  puerperal  state  has  succeeded  that  of  labor.  The  phenomena  and 
management  of  puerperality  will  be  studied  hereafter. 


CHAPTER   XIII. 

THE   CONDUCT   OF    LABOR    (CONTINUED) — OCCIPITO-POSTERIOR   POSI- 
TIONS— FACE,   BROW,    AND   PELVIC   PRESENTATIONS — TWINS. 

THE  MANAGEMENT  OF  OCCIPITO-POSTERIOR  POSITIONS.  As  has 
been  stated,  in  almost  all  cases  of  right  or  of  left  occipito-posterior 
positions  the  occiput  rotates  in  front  and  the  head  is  delivered  as  in  an 
original  occipito-anterior  position.  The  labor  is  longer  and  the  suffer- 
ing greater.  In  exceptional  cases,  when  by  perversion  of  rotation  the 
occiput  turns  into  the  sacral  cavity,  the  delivery  of  the  head  causes  in- 
creased danger  to  the  perineum,  and  the  long  and  difficult  labor  greatly 
endangers  the  life  of  the  child. 

The  tediousness  of  auterior  and  the  possibility  of  posterior  rotation 
have  led  many  obstetricians  to  urge  the  importance  of  manual  or  even 
of  instrumental  means  to  effect  or  assist  the  former. 

Smellie  was  among  the  first  to  claim  that  such  rotation  could  be  effected  by 
the  hand  or  by  an  instrument.  He  stated,  referring  to  the  former  means,  that 
"  turning  the  forehead  into  the  hollow  of  the  sacrum  might  be  assisted  by  intro- 
ducing some  fingers  or  the  whole  hand  into  the  vagina  during  a  pain,  and  mov- 
ing it  to  the  right  position."  Portal  and  Leroux  advised  pressing  with  the  hand 
upon  the  abdominal  wall  so  as  to  withdraw  the  face  from  the  anterior  pelvic 
wall.  Velpeau  taught  that  when  the  head  had  descended  into  the  pelvic  cavity, 
almost  immediately  after  the  escape  of  the  waters,  two  or  three  fingers  should  be 
placed  just  before  the  sacrum,  in  order  to  push  the  occiput  in  front  or  behind 
the  pubes,  upon  the  side  of  the  forehead,  in  order  to  press  the  latter  backward. 
Meigs,  referring  to  delay  in  labor  from  failure  of  anterior  rotation,  directed  that 
two  fingers  should  be  placed  upon  the  child's  head,  just  behind  the  ledge  formed 
by  one  of  the  parietal  bones  overriding  the  occipital,  and  then  drawing  the  ver- 
tex down,  thus  increasing  flexion;  he  added,  "If  such  gentle  measures  will  not 
succeed,  we  have  the  powerful  resource  of  half  the  hand,  which  may  be  intro- 
duced into  the  vagina,  and  sometimes  within  the  cervix,  and  which,  taking  the 
head  in  its  palm  and  fingers,  can  place  the  vertex  wherever  it  may  be  desirable 
to  fix  it."  Hodge's  view  was  that  anterior  rotation  could  generally  be  caused  by 
pressing  on  the  temple  during  a  "  pain  "  and  also  in  the  interval ;  the  pressure 
should  be  made  upon  the  left  temple  in  right  occipito-posterior,  upon  the  right 
temple  in  left  occipito-posterior  position.  Mattel  believed  that  he  had  often 
succeeded  in  effecting  anterior  rotation  of  the  occiput  by  acting  upon  each  pole 
of  the  foetal  ovoid,  the  fingers  of  the  right  hand  being  used  to  draw  the  occiput 
in  front,  while  the  left  hand  was  applied  to  the  fundus  of  the  uterus  to  cause  a 
corresponding  rotation  of  the  trunk.  Tarnier  advises  this  plan :  When  the  os 
is  nearly  or  quite  dilated  introduce  the  index  finger — the  left  one  in  right  occi- 
pito-posterior position — and  apply  it  to  the  cranial  surface  immediately  behind 
the  left  ear  of  the  foetus,  thus  securing  a  good  purchase ;  at  the  beginning  of  a 
uterine  contraction  the  finger  is  pressed  firmly,  but  without  violence,  at  the  same 
time  bringing  the  head  toward  the  pubes,  then  to  the  joint,  and  finally  to  the 
opposite  side,  so  that  the  occiput  is  directly  in  front.  The  first  attempt  often 
succeeds,  but  if,  after  being  repeated  two  or  three  times,  there  is  still  failure,  it 
is  better  to  desist. 

Angus  MacDouald1  held  that  in  all  persistent  occipito-posterior 
positions  we  may  safely  assume  we  have  some  pelvic  peculiarity  or 

i  Transactions  of  the  Edinburgh  Obstetrical  Society,  vol.  iii. 


THE  COND UCT  OF  LABOR.  319 

disproportionately  large  head  to  deal  with,  and,  as  a  rule,  all  attempts 
at  rectification  of  the  position  of  the  head  will  prove  abortive,  and  are 
even  dangerous  if  attempted  by  means  of  levers,  forceps,  etc.  Not  dis- 
similar was  the  teaching  of  Cazeaux ;  he  regarded  all  manoeuvres  to 
effect  anterior  rotation  as  quite  useless.  So,  too,  Charpentier  looks  upon 
manual  efforts  as  in  vain,  and  when  they  appear  to  succeed  the  rotation 
would  occur  without  them. 

THE  MANAGEMENT  OF  FACE  PRESENTATIONS.  The  older  obste- 
tricians advocated  in  presentation  of  the  face  either  changing  it  into  that 
of  the  vertex  or  podalic  version.  Louise  Bourgeois,  1710,  remarked 
that  when  the  chin  advanced  first  in  the  passage  delivery  was  impossi- 
ble, and  the  hand  must  be  introduced  to  push  back  the  chin  upon  the 
chest.  Baudelocque  advised  the  same  method,  and  if  it  failed  only 
podalic  version  or  instrumental  delivery  remained.  Smellie  said  that 
when  the  "  face  presents  resting  upon  part  of  the  pelvis,  the  head  ought 
to  be  pushed  up  to  the  fundus  of  the  uterus,  the  child  turned  and 
brought  by  the  feet."  He  admitted,  however,  that  in  some  instances  - 
spontaneous  delivery  occurred.  Paul  Portal,  1685,  nearly  a  century 
before  Smellie  made  the  statement  I  have  quoted,  was  contented  with 
"  anointing  the  woman's  parts  with  butter  in  order  to  soften  and  relax 
them,  thus  making  the  escape  of  the  infant  easier : "  he  stated  that  the 
accoucheur  should  be  careful  not  to  produce  any  irritation  with  his  finger, 
otherwise  he  will  cause  a  thousand  times  more  injury  to  the  mother  and 
to  the  child  than  the  accouchement,  which  has  no  more  mystery  than  a 
natural  labor.  It  was  not,  however,  until  Lachapelle  asserted  that  these 
labors  terminated  as  easily  as  those  with  vertex  presentation  that  the 
profession  generally  abandoned  interference,  leaving  the  delivery  to 
nature.  Nevertheless  the  affirmation  of  the  perfect  safety  of  labor  in 
presentation  of  the  face  is  somewhat  an  exaggeration,  and  the  profession 
is  not  unanimous  in  regard  to  the  uselessness  of  intervening.  Hodge 
held  that  when  the  practitioner  was  called  early,  and  recognized  a  face 
presentation,  he  should,  after  the  os  is  dilated  and  before  the  presenting 
part  has  passed  this  opening,  substitute  the  vertex,  for  under  these  cir- 
cumstances, especially  in  multiparous  women,  the  operation  can  be  easily 
and  rapidly  performed  without  much  suffering  to  the  mother. 

Partridge  has  also  advocated  this  plan  of  treatment,  stating  the  conditions 
favorable  to  it  and  the  method,  as  follows:  "An  os  nearly  or  quite  dilated;  a 
face  not  engaged  in  or  at  least  capable  of  being  lifted  from  the  pelvic  brim ;  an 
unruptured  bag  of  waters ;  a  capacious  vagina.  In  the  majority  of  labors  a 
stage  is  reached  when  these  conditions  are  present.  Chloroform  to  relax  the 
structures  of  the  parturient  canal,  to  quiet  the  movements  of  the  patient,  and  to 
obviate  pain  caused  by  the  introduction  of  the  hand  into  the  vagina,  is  of  pri- 
mary importance.  The  manipulation  requires  the  presence  of  the  fingers  only 
in  the  uterus,  and  does  not  involve  any  laceration  of  the  cervix.  Passing  the 
palms  of  the  fingers  over  the  occipital  bone,  and  pressing  them  firmly  against  it, 
traction  downward  should  be  made.  In  our  endeavors  flexion  of  the  head  almost 
immediately  commenced  and  quickly  became  complete.  The  other  hand  aided 
greatly  by  external  manipulation."1 

Schroder;  referring  to  conversion  of  a  face  into  a  vertex  presentation,  stated 
that  Thorn  succeeded  in  9  cases  of  24  in  accomplishing  this  change  without  diffi- 
culty ;  and  further,  he  is  correct  in  asserting  that  a  good  result  is  not  to  be  had 

1  American  Journal  of  Obstetrics,  1884. 


320  PHYSIOL  OGY  OF  LAB  OB. 

by  external  and  internal  manipulation  of  the  head  alone,  still  less  as  Schatz 
proposes  by  external  manipulation  of  the  head  and  shoulder,  but  that  the  half 
or  the  whole  of  the  hand  should  be  used  internally  to  turn  the  head,  while  the 
external  hand  is  employed  to  press  it  toward  the  chest,  and  finally  pushing  the 
breech  to  the  other  side  so  as  to  change  the  position  of  the  body. 

Penrose's1  method  of  treating  face  presentations  is  as  follows :  "The  assistance 
which  I  advise  in  all  cases  of  face  presentations  of  mento-anterior  positions  is, 
as  soon  as  the  mouth  of  the  uterus  is  dilated  and  the  face  has  fairly  engaged,  to 
apply  the  hand,  the  lever,  or  the  blade  of  the  forceps  to  the  posterior  cheek,  to 
bring  artificially  a  force  of  resistance  to  bear  on  the  face,  inasmuch  as  the  face 
cannot  secure  this  force  of  resistance  from  the  muscles  of  the  pelvic  floor,  as  the 
vertex  does  in  vertex  presentations,  and  therefore  the  chin  does  not  rotate,  or 
does  so  slowly  and  uncertainly,  to  that  part  of  the  pelvic  cavity  where  a  spon- 
taneous termination  of  labor  is  alone  possible.  If  the  medical  attendant  apply 
this  force  of  resistance  at  the  time  and  in  the  manner  I  have  directed,  rapid  rota- 
tion will  be  secured  and  the  labor  will  terminate  speedily  and  safely." 

In  case  the  chin  is  posterior  and  is  seen  in  time — that  is,  before  the  face  has 
passed  the  mouth  of  the  uterus — he  urges  prompt  employment  of  cephalic  or  of 
podalic  version. 

Pinard,  too,  advises  changing  a  face  into  a  vertex  presentation.  His  method 
is  acting  upon  the  forehead  with  two  fingers  introduced  into  the  vagina,  pressing 
the  forehead  up,  while  the  other  hand  is  used  through  the  abdominal  wall  to 
press  the  occiput  down  ;  the  manoeuvre  is  generally  successful.  Most  obstetri- 
cians will  agree  that  if  the  head  has  not  escaped  from  the  os,  and  if  the  chin 
is  posterior,  that  the  effort  should  be  made,  especially  by  the  method  of  Pinard, 
to  convert  the  presentation  into  that  of  the  vertex.  Kunge  takes  the  ground 
that  the  treatment  of  this  presentation  should  be  expectant.1 

In  conducting  the  labor,  the  presentation  remaining  unchanged,  the 
obstetrician  must  exercise  great  care  in  digital  examination  lest  injury 
be  done,  especially  to  the  eyes.  It  is  better  frankly  to  tell  the  patient 
that  the  labor  will  be  protracted,  but  at  the  same  time  she  may  be  as- 
sured that  it  is  almost  certain  to  have  a  fortunate  issue  both  for  herself 
and  for  her  child.  Friends  who  are  with  her  ought  to  be  informed  of 
the  probably  very  great  disfigurement  of  the  child's  face,  the  statement 
being  also  made  that  this  is  sure  to  disappear  in  a  few  days.  Great 
danger  comes  to  the  child  in  the  disengagement  of  the  head,  for  during 
this  the  throat  is  pressed  against  the  pubic  arch,  and  if  delay  occurs  it 
may  be  necessary  actively  to  assist  the  delivery. 

MANAGEMENT  OF  BROW  PRESENTATIONS.  As  extension  of  the 
head  gives  preseutatiou  of  the  face,  so  partial  extension  results  in  pre- 
sentation of  the  forehead  or  brow.  Upon  digital  examination  the  apex 
ot  the  forehead  is  found  to  be  the  lowest  part  of  the  head,  the  suture 
between  the  two  halves  of  the  frontal  bone  can  readily  be  traced  to  the 
anterior  fontanelle,  and  in  the  opposite  direction  the  different  parts  of 
the  face  are  found.  Now  it  is  almost  certain  that  the  presentation  of 
the  forehead  will  be  only  temporary ;  for  either  flexion  occurs,  and  the 
vertex  presents,  or,  and  this  is  the  more  frequent,  extension  becomes 
complete,  and  the  final  presentation  is  the  face.  If  the  head  be  small, 
spontaneous  delivery  is  possible  without  change  of  presentation.  Klein- 
wachter  takes  the  ground  that  when  the  head  is  in  the  pelvic  cavity  an 
attempt  to  substitute  the  vertex  for  the  face  is  not  to  be  made,  for  even 
if  successful  the  head,  which  has  already  been  more  or  less  moulded 
into  the  form  necessary  for  delivery,  must  undergo  a  new  configuration 

1  American  System  of  Obstetrics,  vol.  i.  2  Op.  cit. 


THE  CONDUCT  OF  LABOR  321 

for  delivery  with  a  new  presentation,  and  thus  time  is  lost,  to  the  dan- 
ger of  both  mother  and  child.  Hodge  taught  that  a  brow  presentation 
should  be  converted  into  that  of  the  vertex  as  soon  as  the  os  uteri  is 
sufficiently  dilated  for  the  passage  of  the  hand  of  the  practitioner. 
Even  when  the  head  has  passed  the  os  he  thought  this  could  be  done 
in  many  cases.  Possibly  his  advocacy  of  an  early  active  interference 
arose  from  the  fact  that  he  did  not  recognize  the  almost  unexceptionally 
spontaneous  change  of  presentation,  for  he  cautiously  observes,  "  per- 
haps in  the  majority  of  cases  "  this  change  occurs.  Hildebrandt  directs 
that  in  persisting  brow  presentation  the  woman  should  be  placed  upon 
her  side  across  the  bed,  and  the  practitioner  then  apply  two  fingers  of 
the  right  hand,  at  the  beginning  of  a  uterine  contraction,  upon  the 
forehead  and  exert  a  pressure  directed  toward  the  occiput  if  a  facial 
presentation  is  desired,  or  toward  the  face  if  descent  of  the  occiput  is 
preferred.  Long  advises  the  same  method,  but  urges  the  importance 
of  conversion  into  a  vertex  presentation.  He  adds  :  "  If  this  is  unsuc- 
cessful, the  whole  hand  should  be  introduced  into  the  vagina  and  the 
fingers  passed  up  over  the  occiput,  pushing  the  head  up  first  if  neces- 
sary, and  then  drawing  downward  upon  the  occiput,  and  with  the 
thumb  pushing  up  the  brow  as  well  as  possible,  so  that  the  head  should 
be  completely  flexed.  Assistance  can  sometimes  be  had  by  external 
manipulation  with  the  other  hand,  and  sometimes  by  having  the  woman 
in  the  knee-chest  position.  Anaesthesia  should  always  be  induced  in 
order  to  relax  the  parts  and  render  the  manipulation  painless."1  Thorn's 
method,  previously  stated,  may  be  employed  in  this  as  well  as  in  pre- 
sentation of  the  face. 

THE  MANAGEMENT  OF  PELVIC  PEESENTATIONS.  The  practitioner 
must  guard  against  an  early  rupture  of  the  membranes,  and  even 
though  the  first  stage  of  labor  is  protracted  it  is  well  to  have  the 
woman  lying  down  most  of  the  time.  No  effort  should  be  made  to 
hasten  delivery  during  the  expulsion  of  the  lower  half  of  the  body ;  no 
traction  upon  the  trunk  is  to  be  exerted,  for  it  may  cause  not  only  de- 
parture of  the  chin  from  the  chest,  but  also  of  the  arms  to  the  sides  of 
the  head  or  even  behind  it.  If  kthe  patient  be  anaesthetized,  great  care 
must  be  taken  that  the  anaesthesia  is  not  to  such  a  degree  as  to  lessen 
either  voluntary  or  involuntary  expulsive  power  when  those  forces  are 
essential  for  the  prompt  expulsion  of  the  upper  part  of  the  trunk  and 
of  the  head.  One  hand  protects  the  perineum  during  the  expulsion  of 
the  breech,  which  is  received  by  the  other.  As  soon  as  so  much  of  the 
body  is  born  that  the  umbilical  cord  comes  within  reach,  a  loop  must 
be  drawn  down  to  guard  against  stretching  and  pressure,  and  also  to 
know  by  the  pulsation  the  condition  of  the  child  ;  if  the  cord  be  around 
one  of  the  limbs,  it  should  be  removed  from  this  position ;  next  it  must 
be  placed  in  such  position  that  it  will  be  least  liable  to  pressure  ;  that 
is,  where  there  is  the  most  room  for  it,  and  this  will  generally  be  upon 
one  or  the  other  side  of  the  sacral  promontory.  If  the  arms  have 
departed  from  the  chest,  an  accident  which  is  not  likely  to  occur 
unless  traction  has  been  made  upon  the  trunk,  they  are  to  be  brought 

1  American  Journal  of  Obstetrics,  1885. 
21 


322  PHYSIOLOGY  OF  LABOR. 

down,  the  sacral  arm  first,  by  passing  two  fingers  up  to  the  shoulder, 
and  along  the  inner  side  of  the  humerus,  if  this  be  possible,  to  the 
bend  of  the  elbow,  and  then  by  gentle  pressure  drawing  the  forearm 
over  the  breast,  causing  the  dislocated  member  to  be  returned  by  a 
movement  the  reverse  of  that  which  displaced  it.  But  if  it  is  impos- 
sible to  reach  the  elbow,  the  finger  or  fingers  must  be  passed  over  the 
acromion  and  pressure  made  directly  upon  the  upper  part  of  the 
humerus,  and  gradually  carried  further  toward  the  elbow,  until  both 
are  drawn  down.  Rotation  of  the  face  into  the  sacral  cavity  next  occurs, 
the  shoulders  now  being  transverse  with  reference  to  the  vulval  orifice  ; 
it  may  be  assisted  by  making  external  rotation  of  the  shoulders. 

DELIVERY  OF  THE  HEAD  IN  HEAD-LAST  LABOR.  Although  plac- 
ing here  much  which  would  be  properly  presented  in  the  chapter  upon 
obstetric  operations,  it  seems  to  me  best  now  to  consider  the  different 
manual  means  used  in  the  delivery  of  the  head  when  it  comes  last. 

FIG.  138. 


ARTIFICIAL  DELIVERY  OF  THE  HEAD  IN  PELVIC  PRESENTATION. 

1.  Continued  flexion  of  the  head  is  sought  by  assisting  uterine  con- 
traction with  manual  abdominal  pressure,  and  by  passing  two  fingers 
of  one  hand  into  the  vagina  which  press  upon  the  superior  maxillary, 
while  two  fingers  of  the  other  hand  push  the  occiput  up.    This  method 
is  illustrated  in  the  subjoined  figure. 

Smellie1  employed  it,  and  it  will  usually  be  successful. 

2.  That  which  is  called  the  Prague  method,  though  probably  origin- 
ating with  Puzos,  is  traction  upon  the  child  by  grasping  the  ankles 
with  one  hand,  while  the  other  is  placed  over  the  shoulders,  three  fingers 
on  one  side  of  the  neck,  the  thumb  and  index  finger  upon  the  opposite 
side ;  the  pull  is  at  first  downward  and  backward  until  the  head  has 

i  Smellie  performed  traction  upon  the  lower  jaw  in  these  cases,  and  it  was  oiuy  when  he  "  was 
afraid  of  overstraining  it "  that  he  changed  the  pressure  of  his  fingers  to  the  supeiior  maxillary. 


THE  CONDUCT  OF  LABOR. 


323 


entered  the  pelvis,  then  upward  and  forward,  the  back  of  the  child 
coming  nearer  the  mother's  abdomen  as  the  head  emerges  from  the 
vulva. 

3.  A  better  method  is  represented  in  the  annexed  illustration.  It 
was  employed  by  Mauriceau,  but  is  commonly  known  as  the  Veit- 
Smellie  method.  It  will  be  seen  in  the  illustration  that  two  fingers  of  one 

FIG.  139. 


MANUAL  EXTRACTION  OF  THE  AFTER-COMING  HEAD  :  COMBINED  TRACTION  UPON  MOUTH 
AND  SHOULDERS  (VEIT'S  METHOD). 

hand  are  passed  into  the  mouth  to  exert  traction  upon  the  lower  jaw, 
while  the  fingers  of  the  other  hand  pull  upon  the  shoulders ;  flexion  is 
secured  partly  by  the  direct  force  exerted  upon  the  inferior  maxilla, 
and  partly  indirectly  By  the  resistance  furnished  at  the  pubic  joint  to 
the  descent  of  the  occiput.1  The  trunk  must  be  lifted  up  as  the  head 
descends  further  into  the  vulvo-vaginal  canal. 

4.  This,  known  as  the  Wigand-A.  Martin  method^Js  the  best2  of  all 
in  a  difficult  delivery,  and  when  it  is  important  it  shall  be  quickly 
effected.  It  is  seen  that  two  fingers  of  one  hand  are  introduced  into 
the  child's  mouth  which  pull  upon  the  lower  jaw,  while  the  other  hand 
is  used  to  press  through  the  abdominal  wall  upon  the  head ;  traction 
and  expression  are  thus  combined. 

While  as  a  rule  in  head-last  labor  the  face  rotates  into  the  sacral 
cavity,  the  reverse  rotation  may  occur,  and  the  occiput  is  found  pos- 
teriorly, deflection  may  follow  and  the  chin  rest  over  the  pubic  joint. 
It  is  necessary  in  such  condition  that  the  occipital  end  of  the  occipito- 

1  Litzmann,  Centralblatt f.  Gynakol.,  1887,  referring  to  the  method  commonly  "known  as  the 
Veit-Smellie,  which  ought  to  be  called  the  Mauriceau-Levret,"  modifies  it  according  to  the  sug- 
gestion of  d'Outrepont  thus :  The  nucha  is  seized,  between  the  index  and  ring-finger,  the  medius 
is  placed  against  the  occiput  behind  the  pubic  joint,  and  is  used  to  press  it  upward  ;  later,  when 
stronger  traction  upon  the  shoulders  is  to  be  made,  the  medius  is  replaced  by  the  ring-finger. 

2  Eisenhart,  assistant  at  the  Munich  Frauenklinik,  has  published  a  paper,  Archiv  f.  Gyna- 
kol., 1889.  contrasting  this  with  the  Veit-Smellie  method,  and  from  comparing  the  results  of 
the  two  in  a  large  series  of  cases  arrives  at  this  conclusion  :  The  delivery  of  living  children,  and 
of  children  that  continue  living,  is  at  least  seven  times  greater  when  pressure  is  made  upon  the 
after-coming  head  by  the  Wigand-Martin-Winckel  method  than  when  the  Mauriceau-Lachapelle 
(Veit-Smellie)  method  was  employed.    Herzfeld,  Centralblatt  f.  Gynakol.,  1890,  comparing  the 
results  from  the  Mauriceau  (Smellie-Veit)  method  in  head-last  labor,  gives  preference  to  this  over 
the  Wigand-Martin,  and  considers  that  it  may  replace  the  forceps.    His  statistics  show  a  slight 
preponderance  of  the  Mauriceau  method  in  favorable  results. 


324 


PHYSIOLOGY  OF  LABOR. 


mental  pole  pass  out  first,  and  therefore  in  the  delivery  of  the  child 
the  body  is  carried  upward  and  forward,  abdomen  of  the  infant  toward 
the  abdomen  of  the  mother. 

In  any  of  these  methods  in  which  the  fingers  are  introduced  into  the 
mouth  great  care  must  be  taken  lest  injury  is  done  with  a  nail  to  the 
delicate  mucous  membrane ;  I  have  seen  one  child  bleed  to  death  from 
injury  thus  inflicted,  and  while  I  know  that  the  obstetrician  usually 
comforts  himself  with  the  reflection  that  the  child  was  ua  bleeder,"  I 
am  not  sure  that  the  explanation  is  always  true ;  the  hemorrhage  may 
occur  when  there  is  not  the  slightest  proof  of  any  hereditary  influence. 

FIG.  140. 


WIGAND-MARTIN  METHOD.    (WINCKEL.) 

As  to  the  amount  of  force  that  may  be  safely  exerted  in  traction  upon 
the  lower  jaw,  Matthews  Duncan  from  his  experiments  states1  that 
fifty-six  pounds  may  be  applied,  in  some  cases,  by  dragging  the  lower 
jaw  without  producing  any  easily  discovered  injury  of  parts. 

A  serious  source  of  delay  in  the  delivery  of  the  head  arises  in  some 
cases  from  contraction  of  the  os  uteri  around  the  neck  of  the  child, 
causing  a  dangerous  compression  of  the  throat.  Depaul,  who  has  de- 
scribed the  occurrence  of  this  obstacle,  advised  the  use  of  the  fingers, 
introduced  into  the  os  to  dilate  it,  and,  if  resistance  continues,  incisions. 

PEESENTATION  OF  THE  HIPS.  Delay  in  the  delivery  of  the  pelvis 
in  the  usual  form  of  pelvic  presentation  may  require,  in  the  interest  of 
the  mother  or  of  the  child,  manual  assistance,  and  there  is  usually  no 
difficulty  in  bringing  down  one  foot,  or  both  feet,  so  that  traction  can 
then  be  readily  exerted.  There  is,  however,  an  unusual  form  of  pre- 

1  London  Obstetrical  Society's  Transactions,  vol.  xx. 


CONDUCT  OF  LABOR.  325 

sentation  in  which  not  only  are  the  thighs  flexed  upon  the  abdomen, 
but  the  legs  extended  upon  the  chest ;  it  is  described  by  French  obste- 
tricians as  presentation  des  f  esses  or  as  presentation  du  siege  d£complete, 
mode  des  f  esses.  The  lower  limbs  iu  this  position  act  as  a  splint  to  the 
body,  and  make  it  rigid  and  inflexible.  The  diagnosis  of  presentation 
by  abdominal  palpation  presents  a  peculiar  difficulty  from  the  vicinity 
of  the  feet  to  the  head,  for,  as  a  rule,  when  a  solid,  round  body  is  felt 
with  small  mobile  parts  near  it,  the  conclusion  justly  drawn  is  that  the 
body  is  the  hips,  so  that  in  a  case  of  this  variety  of  pelvic  presentation 
the  error  of  believing  that  the  head  is  in  the  lower  part  of  the  uterine 
ovoid  can  be  very  readily  committed.  It  may  be,  too,  that  the  hips 
have  entered  the  pelvic  cavity  before  the  labor  begins,  and  hence  new 
difficulty  and  increased  liability  to  error  in  diagnosis  by  abdominal  pal- 
pation. These  cases  are  the  most  unfavorable  variety  of  pelvic  pre- 
sentation, and,  as  a  rule,  assistance  is  necessary. 

Lefour,  in  an  interesting!  paper,1  refers  to  primitive  cases  of  this  anomalous 
position  of  the  lower  limbs  as  distinguished  after  birth  by  the  fact  that  though 
the  limbs  be  drawn  down,  immediately  when  they  are  free  from  constraint  they 
return  to  the  position  they  had  in  the  uterus.  Fig.  141  shows  this  peculiarity. 

FIG.  141.  • 


POSITION  OF  LOWER  LIMBS  IN  CHILD  BORN  WITH  PRESENTATION  OF  THIGHS. 

TREATMENT.  There  will  be  presented  not  only  the  means  necessary 
in  this,  but  in  other  cases  of  difficult  and  delayed  pelvic  delivery. 

The  forceps  may  be  rejected  as  a  most  uncertain,  and  possibly  unsafe, 
means  if  there  is  really  a  serious  delay  in  the  delivery  of  the  hips.  I 
do  not  believe  this  instrument  can  be  safely  used  to  overcome  any  great 
resistance  under  such  circumstances. 

The  blunt  hook  applied  over  the  anterior  thigh  is  frequently  used. 
Fig.  142.  There  is  danger  of  fracturing  the  thigh  ;  Bitot  has  shown 
that  the  femur  will  be  fractured  by  a  force  of  fourteen  to  fifteen  kilo- 
grammes acting  perpendicularly  to  the  axis  of  the  femur.  By  consult- 
ing Fig.  143  it  will  be  seen  that  any  traction  upon  the  anterior  hip  is 

Contribution  a  1' Etude  des  Presentations  du  Siege  decompleW,  mode  des  Fesses. 


326 


PHYSIOLOGY  OF  LABOB. 
FIG.  142. 


BREECH  PRESENTATION.    APPLICATION  OF  THE  BLUNT  HOOK. 

not  made  directly,  only  indirectly,  upon  the  part  which  ought  to  be 
first  advanced,  the  posterior  hip,  and  therefore  there  is  loss  of  force. 


THE  CONDUCT  OF  LABOR.  327 

Nevertheless  the  blunt  hook  may  prove  useful ;  that  of  Delore  is  to  be 
preferred. 

The  fillet  as  advised  by  Galabiu  may  be  tried.  A  soft,  oiled  hand- 
kerchief may  be  used  for  the  fillet ;  a  knot  is  tied  in  it  at  two  opposite 
corners.  By  means  of  the  forefinger  the  corner  is  to  be  passed  from 
without  inward  over  the  flexure  of  the  groin  till  the  knot  can  be 
reached  between  the  thighs  and  drawn  down.  In  the  same  way  the 
opposite  end  of  the  fillet  is  to  be  passed  from  within  outward  over  the 
other  thigh.  The  centre  of  the  fillet  is  then  slipped  up  over  the  but- 
tocks till  it  surrounds  the  sacrum,  and  traction  is  made  by  the  ends.  In 
this  way  the  pressure  is  distributed  over  both  groins  and  the  circumfer- 
ence of  the  pelvis. 

FIG.  143. 


BUDIN  AND  LEFOUK'S  METHOD  OF  TRACTION. 

With  such  a  fillet  traction  is  not  only  exerted  over  a  great  extent  of 
surface,  and  therefore  with  less  danger  of  injury,  but  the  pull  may  be 
made  approximately  in  the  line  of  resistance.  If  the  fillet  be  placed 
over  either  thigh,  the  danger  of  its  slipping,  and  producing  fracture 
of  the  femur,  is  not  slight.  Moreover,  the  application  of  the  fillet 
when  the  hips  are  firmly  pressed  in  the  pelvic  canal,  possibly  consider- 
ably swelled,  is  by  no  means  easy,  and  may  be  impossible. 

Traction  with  the  finger  in  the  anterior  groin  may  not  be  difficult, 
but  the  force  exerted  is  not  great,  and,  as  previously  explained,  works 
at  a  disadvantage ;  much  of  it  is  lost.  If  the  hand  is  introduced  pos- 
teriorly to  carry  a  finger  over  the  periueal  hip,  traction  upon  which  will 
obviously  be  much  more  advantageous,  very  probably  the  hips  will  be 
pushed  up  by  the  entering  hand. 


328  PHYSIOLOGY  OF  LABOR. 

Budin  and  Lefour  advise  passing  one  finger  in  the  anus  of  the  patient, 
and  through  the  anterior  wall  of  the  rectum  hooking  it  over  the  pos- 
terior groin,  while  the  index  finger  of  the  other  hand  is  passed  over  the 
anterior  groin,  and  traction  then  exerted  by  the  two  fingers,  as  shown 
in  the  illustration.  This  method  has  succeeded. 

Finally,  the  method  advised  by  Barnes  is  to  be  commended,  and  in 
general  it  may  be  stated  that  when  the  obstetrician  in  a  pelvic  presenta- 
tion brings  down  a  foot,  he  is,  as  Dr.  Goodell  happily  expressed  it,  com- 
mander of  the  situation,  able  if  delay  occurs  efficiently  to  assist  the  de- 
livery. 

Barnes1  decomposes  the  wedge  by  bringing  down  a  foot,  stating  that 
he  has  on  several  occasions  brought  a  live  child  into  the  world  after 
forceps,  hooks,  and  various  other  means  had  been  tried  in  vain  for  many 
hours,  by  passing  his  hand  into  the  uterus  and  bringing  down  a  foot. 
His  directions  are  as  follows :  u  Place  the  patient  on  her  left  side ;  pro- 
duce anaesthesia  to  the  surgical  degree ;  support  the  fundus  of  the  uterus 
with  your  right  hand  on  the  abdomen ;  pass  your  left  hand  into  the 
uterus,  insinuating  it  gently  past  the  breech  at  the  brim,  the  palm  being 
directed  toward  the  child's  abdomen,  until  you  reach  a  foot — the  anterior 
foot  is  the  better  to  take;  a  finger  is  then  hooked  over  the  instep,  and 
drawn  down  so  as  to  flex  the  leg  upon  the  thigh.  Maintaining  your 
hold  upon  the  foot,  you  then  draw  it  down  out  of  the  uterus,  and  thus 
break  up  the  wedge." 

The  importance  of  the  proper  management  of  pelvic  presentation,  more  espe- 
cially of  that  variety  which  is  being  here  considered,  and  which  it  seems  to 
me  deserves  a  distinct  name,  and  I  therefore  call  it  femoral,  is  so  great,  that  I 
introduce  here  directions  which  otherwise  would  be  included  in  Obstetric  Opera- 
tions :  it  seems  to  me  that  the  difficulty  and  the  means  of  remedying  it  should 
be  in  immediate  connection. 

When  the  obstetrician  decides  in  a  pelvic  presentation  to  bring  down 
a  foot,  two  questions  are  to  be  first  answered  :  Which  is  the  good  hand? 
and,  Which  is  the  good  foot  ?  The  good  hand  is  that  which  corresponds 
with  the  anterior  plane  of  the  fetus.  The  good  foot  is  that  which  be- 
longs to  the  anterior  hip  of  the  fetus.  In  the  subjoined  drawing,  Fig. 
144,  the  operator  instead  of  seizing  the  anterior  foot  has  brought  down 
the  posterior,  and  consequently  the  anterior  hip  is  caught  upon  the  pel- 
vic girdle  in  front,  and  delivery  becomes  impossible,  unless  the  second 
foot  is  also  brought  down. 

The  next  illustration  shows  that  the  anterior  foot  is  brought  down, 
and  hence  no  difficulty  in  the  hips  entering  the  pelvis. 

But  how  are  we  to  accomplish  what  Barnes  advises,  decompose  the 
wedge,  in  what  the  French  term  mode  des  fesses,  or  what  I  have  called 
the  femoral  variety  of  pelvic  presentation  ?  The  hips,  let  us  suppose, 
are  fixed  in  the  pelvic  entrance,  the  amnial  liquor  discharged,  the  uterus 
closely  embracing  the  fetus,  it  is  impossible,  as  Farabo3uf  and  Varnier 
state,  to  execute  the  plan  of  Barnes,  carrying  the  hand  along  the  ven- 
tral face  of  the  fetus,  and  seize  a  foot  which  is  at  the  same  level  as  the 
head  in  the  fundus  of  the  uterus.  But  as  shown  in  Fig.  146,  the  index 

1  Obstetric  Operations. 


THE  CONDUCT  OF  LABOR. 

FIG.  144. 


329 


THE  WRONG  FOOT  BROUGHT  DOWN.    (FARABCEUF  and  VARNIER.) 

and  medius  can  be  passed  along  the  surface  of  the  anterior  thigh,  press- 
ing it  outward  and  backward,  making  flexion  and  abduction  complete ; 
the  inevitable  consequence  is  flexion  of  the  leg,  and  the  foot  descends  so 


FIG.  145. 


THE  RIGHT  FOOT  BROUGHT  DOWN.    (FARABCEUF  and  VARNIER.) 


330 


PHYSIOLOGY  OF  LABOR. 


that  it  is  readily  caught  between  the  fingers.     This  is  one  of  the  sim- 
plest, most  satisfactory,  and  useful  of  all  obstetric1  manoeuvres. 


FIG.  146. 


PINAKD'S  METHOD  OF  BKINGING  DOWN  THE  FOOT.    (FARABCEUF  and  VARNIER.) 

It  should  be  remembered,  too,  that  this  manoeuvre  readily  secures  a 
foot,  and  may  be  successfully  employed  in  those  cases  in  which  there 
has  not  been  complete  ascension  of  the  legs,  that  occurs  in  the  femoral 
variety,  and  without  violence ;  the  entire  hand  is  not  passed  into  the 
uterus — only  two  fingers.  If  this  method  were  generally  adopted,  I 
believe  the  infant  mortality  in  pelvic  presentation  would  be  materially 
lessened,  and  there  would  be  fewer  instances  of  fractured  femur. 

THE  MANAGEMENT  OF  LABOR  IN  TWIN  PREGNANCIES.  Tarnier's 
statistics  show  that  in  more  than  two-thirds  of  pregnancies  with  twins 
labor  is  premature.  The  reason  for  this  fact  is  the  very  great  disten- 
tion  of  the  uterus.  The  labor  is  usually  longer  in  both  the  first  and  in 
the  second  stage.  The  causes  are  :  the  changes  in  the  cervix,  belonging 
to  the  last  period  of  pregnancy,  have  not  occurred  in  the  majority  of 
cases,  and  hence  increased  resistance  is  to  be  overcome,  the  great  disten- 
tion  of  the  uterus  lessens  its  contractile  power,  and  the  force  distributed 
over  so  large  a  surface  is  less  efficient. 

The  statistics  of  Depaul  and  Tarnier,  embracing  316  twin  labors,  show 
that  in  131  cases  each  foetus  presented  by  the  vertex;  81  times  the  ver- 
tex of  one  foetus  and  the  pelvis  of  the  other  presented,  and  47  times 

i  Pinard's  method  is  simply  a  development  of  that  of  Madame  Lachapelle.  Those  who  will  con- 
sult the  second  volume  of  her  "Pratique  des  Accouchmens,"  1825,  pp.  88,  89,  will  find  that  her 
practice  suggested  the  method  of  Pinard. 


THE  CONDUCT  OF  LABOE.  331 

the  pelvis,  and  then  the  vertex,  while  the  remaining  presentations  were 
of  the  vertex  and  of  the  shoulder,  of  the  pelvis  and  of  the  shoulder, 
vertex  and  face,  face  and  vertex,  etc.  Kleinwachter  makes  vertex  pre- 
sentations 69.58  per  cent,  pelvic  presentations  25.25  per  cent.,  and  trans- 
verse 5.17  per  cent.  Most  frequently  both  fetuses  are  born  with  vertex 
presentation,  49.29  per  cent.,  more  seldom  one  vertex,  the  other  pelvic, 
34.49  per  cent.  Still  more  seldom  does  the  birth  of  both  occur  with 
pelvic  presentation,  or  of  the  first  with  pelvic  and  the  second  with 
shoulder  presentation,  or  both  with  the  latter,  6.23,  6.11,  3.55,  0.33. 

FIG.  147. 


FIRST  CHILD  PRESENTING  BY  THE  VERTEX  ;   SECOND  BY  THE  PELVIS. 
B  and  A,  points  of  maxima  of  intensity  of  sounds  of  the  fcetal  heart. 

While  usually  the  twins  lie  longitudinally  in  the  uterus,  placed  beside  each 
other,  as  represented  in  the  illustration,  in  some  cases  they  may  be  either  one 
above,  or  one  in  front  of  the  other.  A  full  description  of  the  last  two  anoma- 
lous positions  of  twins  has  been  given  by  Budin.1 

In  more  than  one- half  the  cases  the  second  child  is  born  within  twenty 
minutes  after  the  first.  In  one  of  212  cases  given  by  Collins  the  inter- 
val was  twenty  hours ;  twelve  hours  and  forty  minutes  in  1  out  of  188 
cases  observed  in  the  Paris  Maternity  ;  Reuss  gives  an  instance  in  which 
the  interval  was  twenty- six  hours.  When  the  presentation  of  the  first 
child  is  favorable,  the  rule  is  no  interference  is  advisable  in  the  first 
stage  of  labor ;  after  the  os  is  dilated  the  membranes  may  be  ruptured 
and  the  labor  conducted  as  usual.  After  the  child  is  born  the  practi- 
tioner, in  most  cases,  knows  for  the  first  time  that  the  pregnancy  has 

i  Op.  cit. 


332  PHYSIOLOGY  OF  LABOR. 

been  plural ;  he  finds  the  uterus  firm,  nearly  as  large  as  it  was  before 
the  birth  of  the  child,  and  upon  digital  examination  ascertains  that  there 
is  a  second  one  within  the  womb.  In  all  cases  a  second  ligature  of  the 
umbilical  cord  is  imperative,  for  while  there  probably  is  no  vascular  con- 
nection between  the  placentae,  the  possibility  of  its  existence  requires 
guarding  against  destroying  the  life  of  the  second  child  by  hemorrhage. 
All  traction  upon  the  cord  to  remove  the  placenta  from  the  uterus  is 
especially  forbidden.  If  the  mother  desires  to  know  if  she  is  to  have 
another  child,  a  knowledge  which  in  many  cases  is  by  no  means  pleasant, 
let  the  truth  be  frankly  told ;  she  may  at  the  same  time  be  assured  that 
the  labor  will  almost  certainly  be  easy  and  brief,  for  not  only  has  the 
birth-passage  been  fully  dilated,  but  the  second  child  is  generally  smaller 
than  the  first.  If  the  presentation  is  normal,  the  sounds  of  the  foetal 
heart  distinct,  and  the  mother's  condition  favorable — none  of  the  grave 
accidents  of  labor,  such  as  eclampsia  or  hemorrhage,  present — it  is  better 
to  wait  untill  expulsive  pains  return,  and  not  cause  immediate  delivery. 
Supposing  that  the  labor  is  premature,  the  child  expelled  feeble  or  dead, 
and  the  placenta  discharged,  it  is  possible,  as  suggested  by  Depaul,  that 
the  second  child  may  be  carried  to  the  full  period  of  gestation,  and 
therefore  interference  would  be  forbidden.  But  wheu  the  placenta  re- 
mains in  the  uterus  there  is  no  ground  for  this  hope,  and  the  practitioner 
should  not  leave  the  patient  until  she  is  delivered.  As  soon  as  decided 
pains  occur  the  membranes  are  to  be  ruptured,  and  contraction  of  the 
uterus  secured  by  manual  abdominal  pressure  during  and  for  a  time 
after  the  expulsion  of  the  child ;  ergot  may  be  given  immediately  after 
the  delivery  of  the  placenta. 


SECTION  III. 
PHYSIOLOGY  OF  THE  PUERPERAL  CONDITION 


CHAPTER  XIY. 

THE  PHYSIOLOGY  AND  THE  MANAGEMENT  OF  THE  PUERPERAL  STATE. 

PUERPERALITY,  or  the  puerperal  state,  follows  labor,  and  continues 
until  the  genital  organs  return  to  their  condition  prior  to  pregnancy, 
and  is  generally  regarded  as  including  a  period  of  about  six  weeks. 
But  here  a  qualification  of  fact  and  one  of  time  should  be  stated.  There 
is  never  an  entire  restoration  of  the  genital  organs,  especially  in  the 
primipara,  to  their  ante-pregnant  condition,  the  changes  caused  by  ges- 
tation and  labor  are  not  completely  effaced ;  and,  as  will  be  seen  in  the 
study  of  uterine  involution,  some  of  the  phenomena  in  this  process  last 
much  longer  than  the  period  mentioned. 

While  pregnancy  was  marked  by  extraordinary  hypertrophy,  a  re- 
verse process  especially  characterizes  puerperality  ;  construction  distin- 
guishes one,  demolition  the  other.  There  was  a  building  up,  and  now 
there  is  a  tearing  down  and  removal  of  structure  no  longer  needed. 
Moreover,  in  the  early  part  of  the  puerperal  state  a  new  function  is 
called  in  exercise,  that  of  the  mammary  glands;  these  organs,  designed 
to  supply  nourishment  for  the  infant  during  the  first  eight  or  ten 
months  of  extra-uterine  life,  enter  into  action  while  the  ovaries  and  the 
uterus  rest ;  ovulation,  gestation,  and  lactation  are  the  three  character- 
istic functions  of  the  female  organism,  and  they  are  exercised  in  succes- 
sion. 

It  is  important  to  know  the  physiological  phenomena  of  childbed, 
so  that  deviations  from  them  may  be  at  once  recognized,  and,  if  possible, 
promptly  arrested.  The  condition  of  a  woman  after  delivery  has  been 
compared  to  that  of  a  person  who  has  undergone  a  grave  surgical  oper- 
tion ;  neither  is  laboring  under  disease,  but  each  is  more  or  less  ex- 
hausted, and  each  has  undergone  a  traumatism  which  opens  the  doors 
for  the  entrance  of  disease-germs,  and  both  need  intelligent  and  constant 
care  to  guard  against  danger  and  to  guide  to  perfect  recovery. 

The  woman  who  has  just  passed  through  childbirth  usually  enters 
into  a  period  of  calm  rest.  The  stormy  struggle,  the  severe  physical 
suffering,  and  the  anxiety  are  happily  ended  for  most  in  quiet  and 
peaceful  joy.  Generally  the  puerpera  is  disturbed  by  conversation,  or 
by  movement  of  her  body ;  her  replies  to  questions  are  usually  in  a 
low  tone  of  voice  and  brief,  and  she  desires  above  all  things  mental  and 


334  PHYSIOLOGY  OF  THE  PUERPERAL  CONDITION. 

physical  rest.  In  some  cases  there  is  very  great  nervous  prostration, 
presenting,  as  far  as  frequency  of  pulse  and  somewhat  difficult  respira- 
tion are  concerned,  the  characteristics  of  post-partum  hemorrhage,  aud 
the  heart's  action  is  very  feeble,  but  an  error  of  diagnosis  is  easily 
avoided  by  finding  the  uterus  well  contracted  and  the  flow  quite  nor- 
mal. Perfect  rest,  the  administration  of  a  stimulant,  or  a  hypodermatic 
of  sulphuric  ether  with  digitalis  may  be  required.  But  these  are  quite 
exceptional  cases,  and  much  more  frequently  a  chill  occurs.  In  about 
one-third  of  parturients  there  is  a  chill  during  labor,  or  soon  after  ;  the 
latter  is  the  more  frequent.  This  chill,  which  is  oftener  observed  after 
a  rapid  labor,  lasts  from  a  few  minutes  to  a  quarter  of  an  hour ;  it  is 
not  attended  with  any  change  in  the  pulse  or  in  the  temperature.  The 
most  probable  explanation  of  this  phenomenon  is  that  the  organism 
suddenly  loses  a  mass  to  which  it  had  been  progressively  accustomed, 
and  this  rapid  depletion  of  the  abdomen  causes  immediate  cessation  of 
compression  of  the  viscera,  the  blood  leaves  the  exterior  to  fill  the  space 
left  in  these  organs.  But,  whatever  the  explanation,  the  chill  is  physi- 
ological, and  portends  no  danger. 

AFTEK-PAINS.  A  still  more  frequent  cause  disturbing  the  rest  of 
the  newly  delivered  woman,  if  she  be  a  multipara,  is  the  occurrence  of 
painful  contractions  of  the  uterus.  These  are  more  severe  after  a  rapid 
labor ;  indeed  they  may  be  absent  if  it  has  been  slow,  they  only  excep- 
tionally occur  in  primiparse,  and  they  are  more  frequent,  too,  if  the 
uterus  has  been  greatly  distended.  They  generally  begin  a  short  time 
after  the  expulsion  of  the  placenta,  recur  at  intervals  of  five,  ten,  fif- 
teen, or  twenty  minutes,  and  disappear  after  twenty-four  hours ;  they 
are  excited  or  increased  by  the  application  of  the  child  to  the  breast ; 
exceptionally  they  continue  for  two  days,  or  even  somewhat  longer. 
"When  after-pains  are  very  close  together,  and  continue  thus  for  some 
hours,  the  fact  is  cause  for  anxiety,  as  they  may  indicate  the  beginning 
of  a  metro-peritonitis,  aud  the  temperature  of  the  patient  should  be 
carefully  watched. 

Expulsion  of  clots  is  usually  caused  by  these  painful  contractions  of 
the  uterus,  and  when  they  are  moderate  in  severity  their  occurrence  is 
favorable,  for  they  show  a  uterine  activity  which  is  a  safeguard  against 
hemorrhage.  The  diagnosis  ought  not  to  present  any  difficulty,  for  the 
hand  placed  upon  the  abdomen  recognizes  the  contraction  of  the  uterus. 

But  there  may  be  very  severe  attacks  of  "  uterine  colic  "  occurring  within  a 
few  days  after  birth,  in  some  cases  even  causing  marked  temporary  elevation  of 
temperature,  which  are  purely  nervous ;  just  as  there  may  be  vesical  or  rectal 
tenesmus,  so  there  may  be  a  similar  disorder  of  the  uterus,  and  in  each  case  the 
organ  affected  be  quite  empty. 

Prochownick  has  shown1  that  •  in  some  cases  of  diastasis  of  the  abdominal 
muscles  the  intestine  may  protrude  through  the  opening,  and  pain  result,  which 
may  be  mistaken  for  after-pains,  and  probably  is  thus  mistaken  in  many  cases. 
A  careful  examination  will  recognize  the  cause  of  suffering. 

THE  PULSE.  During  labor  the  pulse  usually  increases  from  70  or 
75  to  90  or  100 ;  but  a  short  time  after  delivery  its  frequency  lessens, 
sinking  below  the  normal  in  from  eight  to  forty-eight  hours ;  usually 

i  Op.  cit. 


MANAGEMENT  OF  THE  PUERPERAL  STATE.  335 

the  pulse  oscillates  between  50  and  60,  but,  according  to  Blot,  between 
44  and  56  ;  Olshausen  makes  it  between  40  and  50,  and  in  rare  cases 
says  it  falls  below  40 ;  the  lowest  that  I  have  observed  was  46. 

The  lessened  frequency  of  the  pulse  was  attributed  by  Marey  to  increased 
blood-pressure,  but  others  assert  that  this  is  diminished ;  by  Olshausen  to  ab- 
sorption of  fat  from  the  uterus,  but,  as  will  be  presently  shown,  fatty  degener- 
ation of  the  uterine  muscular  tissue  does  not  occur ;  to  the  position  of  the  woman, 
and  to  complete  mental  and  bodily  rest.  Winckel  states  that  the  experiments 
of  G.  V.  Liebig  make  it  very  probable  that  there  is  a  causal  connection  between 
the  slowing  of  the  pulse  and  the  increase  of  the  vital  capacity  of  puerperal 
women. 

The  slowing  of  the  pulse  is  justly  regarded  as  a  favorable  indication, 
and  the  slower  the  more  favorable.  The  duration  of  this  condition  is 
usually  several  days,  and  the  period  when  it  is  greatest  is  from  the  fifth 
to  the  seventh  day  (Olshausen) ;  Louage1  states  it  is  the  morning  of  the 
seventh  day.  Buffet  says  the  slow  pulse  lasts  in  multipart  from  five 
to  seven  days,  but  in  primiparse  only  from  three  to  four. 

THE  TEMPERATURE.  During  labor  there  is  generally  some  increase 
in  the  temperature,  and  this  increase  may  continue  for  twelve  hours  or 
more  after;  it  is  a  little  greater  in  primiparse,  and  may  amount  to  two  or 
three  degrees  F.  But  within  twenty-four  hours  the  temperature  declines 
and  remains  stationary  during  seven  or  eight  days,  there  being  only  the 
usual  morning  and  evening  variations.  The  following  table  gives  the 
result  of  the  average  temperatures  of  twelve  patients  in  whom  puer- 
peral convalescence  occurred  without  disturbance ;  the  first  temperature 
was  taken  twenty-four  hours  after  delivery.2 

Morning.       Evening. 

First  day       .  -98.4°  98.8° 

Second  day 98.4  98.8 

Third  day 98.2  98.8 

Fourth  day 98.2  98.4 

Fifth  day 98.2  98.9 

Sixth  day 98.4  98.8 

Seventh  day 98.  98.4 

Eighth  day 98.2  98.4 

The  highest  temperature  observed  in  any  one  of  these  twelve  women 
was  98f  °,  and  this  occurred  on  the  fifth  day.  Transient  elevation  of 
temperature  may  arise  from  mental  causes,  from  disorders  of  the  diges- 
tion, or  from  getting  up  too  soon.  But,  as  Tarnier  remarks,  these 
momentary  elevations  do  not  generally  involve  an  unfavorable  prog- 
nosis ;  it  is  not  the  same  with  those  that  are  progressive  and  continued  ; 
especially  when  the  thermometer  placed  in  the  axilla  ascends  above 
100.4°,  some  complication  ought  to  be  feared. 

RESPIRATION.  The  pulmonary  capacity,  according  to  Dohrn's  in- 
vestigation, increases  in  the  majority  of  cases ;  the  respirations  are  from 
14  to  18  per  minute. 

PERSPIRATION.  Increased  action  of  the  sudoriparous  glands  occurs 
in  the  first  week  of  the  lying-in  ;  the  perspiration  is  especially  abund- 
ant during  sleep.  It  has  been  asserted  that  if  the  patient  have  good 

1  Le  Pouls  Puerperale  Physiologique,  par  Pierre  Louage.    Paris,  1886. 

2  I  am  indebted  to  Drs.  Phillips  and  Randall,  resident  physicians  in  the  Obstetric  Department 
of  the  Philadelphia  Hospital  during  one  of  my  terms  of  service,  for  the  preparation  of  this  table. 


336  PHYSIOLOGY  OF  THE  PUERPERAL  CONDITION. 

nourishment,  if  she  be  lightly  covered,  and  if  the  room  be  well  venti- 
lated this  increase  of  secretion  may  not  occur. 

The  congestion  of  the  skin  of  the  scalp,  according  to  Naegele,  causes 
exudation  in  the  hair-follicles,  and  hence  falling  out  of  some  of  the 
hair  is  not  uncommon.  || 

RENAL  SECRETION.  The  quantity  of  urine  in  the  first  eight  days, 
Kehrer  states,  is  increased  in  comparison  with  that  of  the  non-pregnant, 
but  lessened  in  comparison  with  that  of  the  pregnant  woman.  Milk- 
sugar  is  found  in  the  urine  from  the  third  day,  especially  if  there  be  an 
abundant  secretion  of  milk.  This  is  known  as  a  resorption  glycosuria 
— the  sugar  being  received  into  the  blood  from  the  milk  glands  and 
eliminated  by  the  kidneys ;  it  would  be  more  appropriately  called 
lactosuria. 

Peptone,  according  to  Fischel,  is  found  almost  without  exception  in 
the  urine  from  the  second  to  the  tenth  day ;  it  is  derived  from  metab- 
olism of  albuminous  elements  of  the  uterine  muscle.  The  urine  in  a 
limited  number  of  cases  contains  albumin ;  this  albuminuria  may  be 
simply  that  of  pregnancy,  or  that  originating  in  labor,  continued,  or 
may  now  first  appear.  The  urine  also  contains  small  quantities  of 
acetone.  (Winckel.) 

f  RETENTION  OF  URINE.  Inability  to  evacuate  the  bladder  is  not 
uncommon,  especially  in  primiparse,  if  the  labor  has  been  protracted. 
The  causes  of  the  urinary  retention  are  the  ample  space  given  the  bladder 
to  resume  its  spherical  form,  while  during  the  latter  part  of  pregnancy 
it  was  flattened,  the  swelling  of  the  urethra  and  the  neck  of  the  bladder 
from  severe  compression  in  labor,  the  loss  of  abdominal  pressure,  and 
the  unaccustomed  position  the  patient  occupies  while  attempting  to 
urinate,  that  is,  horizontal.  If  the  bladder  be  distended  with  urine,  the 
uterus  is  carried  higher  up  in  the  abdominal  cavity ;  such  distention, 
too,  may  cause  secondary  hemorrhage. 

CONDITION  OF  THE  DIGESTIVE  ORGANS.  The  desire  for  food  is  less 
in  the  first  two  or  three  days,  but  in  consequence  of  the  activity  of 
various  secretions,  especially  of  the  kidneys  and  the  sudoriparous  glands, 
the  thirst  is  great.  Evacuation  from  the  bowels  is  delayed,  partly 
because  of  their  having  been  so  thoroughly  emptied  in  labor,  and  partly 
because  of  the  character  of  the  food  usually  taken,  and  because  of  the 
woman  being  in  entire  rest. 

PSYCHICAL  CONDITION.  The  newly  delivered  woman  is  peculiarly 
nervous  and  sensitive,  and  disturbed  by  causes  to  which  she  would  be 
ordinarily  indifferent. 

LocHiA.1  This  name  is  given  to  the  flow  from  the  genital  organs  in 
childbed.  The  discharge  comes  chiefly  from  the  placental  site,  and 
there  are  mixed  with  it  fragments  of  the  uterine  decidua ;  in  normal 
cases  it  is  free  from  germs.  Passing  through  the  cervix  glandular 
secretion  of  the  latter  is  added,  and  in  its  further  progress  the  secretions 
of  the  vagina  and  of  the  vulva.  The  uterine  lochia  are  free  from  germs 

1  Ao^/«.  or  Ao^e/a  was  one  of  the  names  given  to  Artemis  or  Diana,  from  her  helping  presence 
at  childbirth.  From  the  adjective  /lo^eZof ,  belonging  to  childbirth,  we  have  the  words  used  by  Hip- 
pocrates, ra  hoxta  and  -fj  /W^a,  the  discharge  after  delivery.  It  would  seem,  therefore,  that 
lochia  may  be  used  in  the  singular  or  in  the  plural. 


MANAGEMENT  OF  THE  PUERPERAL  STATE. 


337 


in  a  normal  puerperium  ;  injected  beneath  the  skin  no  abscess  or  fever 
results  in  human  beings  or  in  animals;  the  flow  is  alkaline.  For  the 
first  four  days  the  lochial  secretion  is  composed  largely  of  blood,  and 
receives  the  name  of  lochia  cruenta.  (Fig.  148,  from  Winckel.)  It 
then  becomes  lighter  in  color  and  thinner,  and  is  called  lochia  scrosa. 
(Fig.  149,  Winckel.) 


FIG.  148. 


FIG.  149. 


LOCHIAL  DISCHARGE  ON  THE  SECOND  DAY. 
A  FEW  ISOLATED  Cocci  AND  STREPTOCOCCI. 
LOCHIA  CRUENTA. 

a.  Decidua  cells,    b.  Red  blood-corpuscles. 
c.  White  blood-corpuscles,    d.  Epithelia. 


FIG.  150. 


LOCHIAL  DISCHARGE  ON  THE  FOURTH  DAY. 
a.  Cells  of  the  decidua.  6.  White  blood-cor- 
puscles, c.  A  few  red  blood-corpuscles,  d. 
Epithelial  cells  without  nuclei  from  the  vernix 
caseosa,  with  nuclei  from  the  parturient  canal ; 
numerous  clusters  of  cocci,  partly  in  cells 
without  nuclei,  which  are  stained  blue  by 
Gram's  method.  X  330. 


FIG.  151. 


LOCHIA,  SEVENTH  DAY.    No  ELEVATION  or  MAMMA  IN  LACTATION.    X  330. 

TEMPERATURE.  a  Colostrum.    6.  Milk. 

a  Blood-corpuscles.  6.  Diplo-  and  Mono- 
cocci,  c.  White  blood-corpuscles,  d.  Epithe- 
lial cells,  e.  Decidual  cells. 

The  eighth  day  it  becomes  yellowish  and  creamlike  ;  it  is  known  as 
lochia  alba.  The  above  illustration  from  Winckel  shows  the  micro- 
scopic appearance  of  the  lochia  on  the  seventh  day  (Fig.  150). 

The  chemical  character  of  the  fluid,  according  to  Doderlein,  in  the 
vagina  favors  the  development  of  saprophytes,  streptococci,  and  staphy- 
lococci ;  inoculation  causes  fever  and  abscess.  (Scherer,  Rokitausky, 
Kehrer,  Karewski.) 

22 


338  PHYSIOLOGY  OF  THE  PUERPERAL  CONDITION. 

The  discharge  is  greater  and  lasts'  longer  in  women  who  do  not 
nurse.  In  normal  cases  the  quantity  is,  in  the  fourth  week,  very  small, 
and  then  usually  ceases,  presenting  before  its  cessation  somewhat  the 
appearance  of  uncoagulated  albumin.  The  amount  in  all  is  about  three 
pounds  and  a  quarter,  the  flow  of  the  first  three  days  being  about  two- 
thirds  of  this  weight. 

During  the  establishment  of  the  milk  secretion  the  lochia  temporarily 
lessen  as  a  rule,  and,  on  the  other  hand,  increase  from  great  exertion  too 
early  after  labor,  or  getting  up  too  soon. 

The  odor  is  not  offensive,  and  should  it  become  so  the  obstetrician  is 
watchful  lest  puerperal  infection  occur. 

Artemieff2  states  that  the  lochia  of  healthy  women  consist  of  blood-corpuscles, 
pavement-epithelium,  mucous  corpuscles,  fatty  degenerated  cells,  and  cells  which 
he  designates  locheiocytes.  In  the  first  few  days  after  labor  red  blood-corpuscles 
predominate,  which  gradually  diminish,  while  the  locheiocytes  become  more 
numerous.  With  a  mixture  of  pavement-epithelia,  mucous  corpuscles,  and  fatty 
degenerated  cells,  the  locheiocytes  constitute  the  lochia  alba.  Locheiocytes  are 
larger  than  pus-cells  in  the  proportion  of  one  to  two-thirds. 

De  la  Motte,  in  his  Traite  des  Accouchemens,  1726,  gives  two  cases  in  which  the 
lochial  flow  entirely  ceased  the  fifth  day,  no  injurious  consequences  being 
observed.  But  my  friend,  Dr.  Darrach,  of  Germantown,  Philadelphia,  has  told 
me  of  a  more  extraordinary  case,  the  lochia  not  appearing  at  all.  Dr.  Darrach's 
patient  was  a  primipara,  twenty-seven  years  old.  After  some  discharge  with  the 
delivery  of  the  placenta  no  flow  occurred  ;  she  had  a  normal  temperature  through- 
out complete  puerperal  convalescence. 

CHANGES  IN  THE  GENITAL  ORGANS.  INVOLUTION  OF  THE  UTERUS. 
A  woman  immediately  after  labor  has  more  or  less  soreness  of  the 
external  organs  of  generation.  They  are  tender,  and  there  is  the  feeling 
of  their  having  been  bruised ;  if  a  primipara,  there  is  more  or  less 
tearing  of  the  vulval  orifice,  such  injury  affecting  the  fourchette,  some- 
times the  nymphse,  less  frequently  the  labia  majora,  and  in  some  cases 
the  anterior  margin  of  the  vulva.  These  various  parts  may  become 
oadematous,  but  this  condition  usually  disappears  in  two  or  three  days, 
and  they  gradually  approximate  their  condition  before  pregnancy.  The 
vagina  becomes  shorter  and  narrower,  but  its  columns  and  rugae  never 
are  so  distinct  as  before  labor ;  its  muscular  tissue  is  atrophied,  while 
the  superficial  epithelium  of  its  mucous  covering  is  exfoliated  ;  during 
the  continuance  of  the  lochial  discharge  there  is  a  catarrhal  vaginitis. 
The  layers  of  the  broad  ligaments,  separated  by  the  growing  uterus, 
re-unite,  and  the  ovaries  and  oviducts  take  their  usual  position  in  the 
true  pelvis. 

But  the  most  remarkable  change  occurs  in  the  uterus.  This  organ, 
which  weighs  soon  after  delivery  2.2  pounds,  two  days  later  only  weighs 
26J  ounces.  At  the  end  of  a  week  it  weighs  about  one  pound,  and  at 
the  end  of  two  weeks  its  weight  is  about  12 £  ounces  (Spiegelberg).  In 
six  or  eight  weeks  it  has  returned  to  nearly  its  size  before  pregnancy. 

1  According  to  the  law  of  the  ancient  Hebrews,  Leviticus  XII.,  a  woman  was  unclean  for  thirty- 
three  days  after  giving  birth  to  a  male  child,  but  for  sixty-six  days  if  the  child  was  female. 
Kehrer,  referring  to  this,  makes  it  equivalent  to  the  statement  that  the  lochia  continued  these 
respective  periods.    (See  Miiller's  Handbuch  der  Geburtshiilie,  vol  i.) 

Hippocrates  taught  that  the  flow  lasted  twenty  to  thirty  days  after  the  birth  of  a  boy,  and  after 
the  birth  of  a  girl  twenty-five  to  forty-two  days. 

2  Zeitschrift  f.  Geburt.  und  Gynakol. 


MANAGEMENT  OF  THE  PUERPERAL  STATE.  339 

The  process  by  which  this  change  is  effected  is  called  involution.  The 
uterus  was  progressively  evolved  in  the  course  of  pregnancy  to  meet  the 
requirements  of  the  new  being,  and  now  that  gestation  has  ended,  there 
being  no  further  use  for  such  size  and  capacity,  the  organ  is  involved.1 

As  Klein wachter  remarks,  uterine  involution  begins  with  the  first 
labor-pains.  He  further  states  that  the  contraction  of  so  large  a  muscle 
must  go  hand-iu-hand  with  a  change  of  matter,  increasing  to  a  high 
degree,  and  although  the  production  of  heat  is  by  the  consumption  of 
non-nitrogenous  substances,  yet  long-continued  and  increased  action  leads 
to  the  destruction  of  the  functionally  active  contents  of  muscle-cells. 
Besides,  the  formation  of  new  protoplasm  is  interfered  with  by  the  com- 
pression of  bloodvessels  during  uterine  contractions,  and  the  involution 
of  the  muscle  is  thus  in  part  affected. 

In  regard  to  the  degree  and  the  character  of  the  changes  that  occur  in  the 
ultimate  muscular  tissue  authorities  are  not  agreed.  According  to  Spiegelberg, 
the  uterine  muscular  substance,  pale  at  delivery,  becomes  yellowish  from  the  sixth 
day,  the  color  being  due  to  a  granulo-fatty  degeneration  of  its  fibres.  But  Robin 
has  stated  that  the  presence  of  minute  drops  of  fat  can  be  seen  from  the  third 
month  of  pregnancy ;  he  adds  that  the  diminution  of  volume  of  the  muscle-fibres 
is  made  solely  by  atrophy  which  occurs  after  labor,  and  he  insists  that  the  fatty 
infiltration  lessens  as  the  muscular  fibres  atrophy.  Heschl's  view,  adopted  by 
most  obstetric  authorities,  attributes  very  great  importance  in  uterine  involution 
to  fatty  degeneration.  This  degeneration  begins  about  the  fourth  or  sixth  day  in 
the  form  of  minute  fat-drops,  which  by  degrees  extend  so  as  to  fill  the  fibre-cells, 
and  soon  effect  their  destruction.  From  the  fourth  week  a  new  formation  is  evi- 
dent in  the  external  muscular  layers,  appearing  first  as  nucleated  cells  which  soon 
become  fibre-cells ;  destruction  and  regeneration  march  side  by  side,  and  toward 
the  eighth  week,  the  latter  is  complete.  Mayor's 2  investigations  led  him  to  con- 
clude that  fatty  degeneration  of  the  "muscular  fibres  was  more  marked  than  Robin 
thought,  but  still  had  not  the  importance  attributed  to  it  by  Heschl.  From  the 
fact  that  it  was  at  its  maximum  at  the  points  where  these  elements  most  rapidly 
resume  their  primitive  volume,  he  regarded  the  degeneration  as  only  a  momen- 
tary transformation  of  the  protoplasm  of  the  cells  designed  to  favor  absorption, 
and  the  disappearance  of  the  materials  which  constitute  the  gravidic  hyper- 
trophy. 

The  doctrine  that  there  is  a  complete  regeneration  of  the  uterus  certainly  seems 
improbable.  Admitting  the  truth  of  Aristotle's  statement,  that  nature  does  noth- 
ing in  vain,  it  seems  utterly  unnecessary  to  destroy  the  whole,  in  order  to  remove 
a  part.  Moreover,  it  is  somewhat  remarkable,  that  if  there  is  such  entire  regener- 
ation, a  new  uterus  in  fact  created,  the  organ  in  another  pregnancy,  and  after 
another  labor,  behaves  so  differently  from  the  primitive  one ;  the  new  uterus  is 
more  readily  distended,  and  preserves  its  typical  form  less  completely ;  after  labor 
it  fails  to  contract  perfectly,  and  thus  permits  the  accumulation  of  blood-clots, 
and  consequent  after-pains.  Nature  may  go  on  constructing  a  new  uterus  a  dozen 
times  even,  and  the  oftener  she  tries,  the  more  the  product  of  her  work  deviates 
from  the  original  pattern. 

Sanger,3  from  his  studies  of  the  regressive  metamorphosis  of  the  muscular  tissue 
of  the  uterus,  arrives  at  a  result  directly  contrary  to  the  statements  of  Heschl 
and  of  Kolliker,  the  former  asserting  entire,  and  the  latter  partial,  destruction  of 
the  muscular  tissue.  He  has  found  that  the  muscular  fibres  during  uterine  in- 
volution lessen  in  length  and  thickness  until  restored  to  their  primitive  form  and 
size.  The  fatty  degeneration  of  the  muscular  parenchyma  has  simply  the  signifi- 

1  Numerous  experiments  have  been  tried  using  ergot  daily  during  the  puerperal  period,  and  the 
conclusion  of  most  observers,  not  of  all,  is  that  involution  of  the  uterus  is  thus  hastened,  but  some 
have  found  that  the  secretion  of  milk  was  lessened.    Involution  is  a  physiological  process,  and 
ergot  is  a  medicine — its  administration  presupposes  a  pathological  condition  ;  the  healthy  puer- 
pera  does  not  need  ergot. 

2  Siredey,  Les  Maladies  Puerperales. 
Central  blatt  f.  Gynakol.,  1888. 


340  PHYSIOLOGY  OF  THE  PUERPERAL  CONDITION. 

cation  of  nutritive  phenomena.  There  is  never  found  external  to  the  muscular 
fibrillee  fatty  detritus ;  the  combustion  of  fat-molecules  takes  place  in  the  interior 
of  the  cell,  so  that  the  lipoemia  to  which  Olshausen  attributed  the  slowing  of  the 
pulse  of  the  puerpera  does  not  exist.  Dittrich,  from  a  study  of  the  involution 
of  the  uterus  in  pathological  states  of  puerperal  women,  embracing  92  cases,1  has 
confirmed  the  view  of  Sa'nger. 

The  restoration  of  the  raucous  membrane  proceeds  at  the  same  time 
as  the  involution  of  the  uterus.  Normally,  the  superficial  layer  of  the 
mucous  membrane,  the  decidua  vera  of  Hunter,  is  detached  and  expelled 
with  the  placenta  and  membranes ;  but  no  small  part  of  it  may  be  re- 
tained, passing  off  by  fatty  degeneration  with  the  lochia.  The  uterine 
glands  retain  their  lining;  these  are  brought  closer  together  by  the 
retraction  of  the  uterus,  from  the  glandular  cul-de-sacs  epithelium  is 
formed,  which  extends  toward  the  uterine  cavity — these  proliferations 
about  the  end  of  the  third  week,  according  to  Leopold,  reaching  the 
surface,  and  at  the  end  of  the  fifth  week  this  investment  is  complete; 
that  is  to  say,  a  new  mucous  membrane,  formed  from  that  lining  the 
glands,  covers  the  uterine  wall.  Very  important  changes  occur  at  the 
site  of  the  placenta.  In  the  eighth  month  some  of  the  venous  sinuses 
are  closed  by  thrombi,  and  after  the  expulsion  of  the  placenta  the  re- 
maining ones  are  closed  in  the  same  way ;  the  thrombi  degenerate  and 
are  gradually  absorbed,  but  the  process  is  not  completed  until  four  or 
five  months  after  labor. 

CHANGES  IN  THE  BLOODVESSELS.  It  is  generally  thought  that  many 
of  these  vessels  are  so  firmly  compressed  by  the  contraction  of  the 
uterus  as  to  undergo  fatty  degeneration  and  absorption.  The  larger 
arteries  are  partially  obliterated  by  proliferation  of  the  connective  tissue 
of  the  intima;  the  media  is  destroyed  by  fatty  degeneration  ;  new  mus- 
cular elements  take  the  place  of  the  degenerated  ones  where  the  vessels 
are  to  remain ;  other  vessels  are  simply  narrowed,  and  continue.  Accord- 
ing to  Balin,  the  regressive  metamorphosis  begins  later  and  lasts  longer 
than  the  same  process  in  the  muscular  structure  of  the  uterus,  occupy- 
ing several  months. 

POSITION  AND  FORM  OF  THE  UTERUS.  Immediately  after  delivery 
the  uterus  is  a  round,  hard  body  reaching  a  little  more  than  four  inches, 
eleven  centimetres,  above  the  pubic  symphysis,  and  very  nearly  the  same 
distance  from  side  to  side.  A  few  hours  later,  either  from  relaxation  or 
from  the  bladder  being  filled,  it  reaches  somewhat  higher ;  subsequently 
a  more  or  less  continuous  diminution  goes  on,  so  that  by  the  tenth  day 
the  fundus  is  at  the  superior  margin  of  the  pubic  joint;  the  daily  de- 
crease in  the  height  of  the  fundus  above  the  pubic  symphysis  being  from 
two-fifths  to  four-fifths  of  an  inch,  or  from  one  to  two  centimetres. 
During  this  time  its  position  varies  with  the  position  of  the  patient,  but 
it  inclines  toward  one  or  the  other  side,  and  does  not  occupy  the  median 
line.  The  puerperal  uterus  is  often  auteflexed,  and  in  some  cases  this 
anteflexion  is  so  great  that  an  obstruction  to  the  passage  of  the  lochia  is 
caused,  and  the  condition  known  as  lochiometra  results. 

Depaul  gave  the  following  as  the  approximate  relative  positions  of  the  fundus 
of  the  uterus  in  the  first  days  of  the  puerperal  state.     The  first  day  it  is  a  finger's 

i  Centralblatt  f.  Gynakol.,  1889. 


MANAGEMENT  OF  THE  PUERPERAL  STATE. 


341 


breadth  above  the  umbilicus ;  the  second  day  at  the  level  of  the  umbilicus ;  the 
third  day  a  little  below  ;  the  fourth  day  but  little  variation  from  the  preceding  ; 
the  fifth  and  the  sixth  clays  two  fingers'  breadth  below ;  the  seventh,  eighth,  and 
ninth  days  three  or  four  fingers'  breadth  above  the  pubic  joint;  the  tenth,  elev- 
enth, and  twelfth  days  at  the  level  of  or  a  little  below  the  pubis. 


FIG.  152. 


PUERPERAL  UTERUS  THE  FIRST  DAYS  OF  THE  LYING-IN.    (After  a  frozen  section  by  WYDER.) 

The  following  is  a  table  given  by  Ahlfeld  as  to  the  position  of  the 
uterus  above  the  symphysis,  and  its  width  in  the  first  ten  days  : 


After  the  discharge  of  the  placenta 

End  of  the  first  day 

End  of  second  day 

End  of  third  day 

End  of  fourth  day 

End  of  fifth  day  . 

End  of  sixth  day 

End  of  seventh  day 

End  of  eighth  day 

End  of  ninth  day 

End  of  tenth  day 

CHANGES  IN  THE  NECK  OF  THE  UTERUS.  Directly  after  birth  the 
neck  of  the  womb  is  relaxed  and  soft,  and  has  been  compared  by  Klein- 
wachter  to  the  vulva  ;  the  canal  admits  three  or  four  fingers  readily, 
but  slight  resistance  is  offered  by  the  internal  os ;  the  length  of  the 
cervix  is  about  2.7  inches,  or  7  centimetres.  At  the  tenth  day  the  canal 
no  longer  admits  even  one  finger,  and  by  the  twelfth  the  neck  is  only  3 
centimetres,  or  a  little  more  thau  an  inch  long,  according  to  Lott. 


Height  above 
Syinphysis. 

Greatest  Breadth. 

11    cm. 

10    cm. 

10.8 

10 

10 

9.6 

9 

8.9 

8.4 

8.6 

7.7 

8 

7 

7.4 

6.6 

7.4 

6.2 

6.6 

5.8 

6.6 

5.5 

342  PHYSIOLOGY  OF  THE  PUERPERAL  CONDITION. 

Loss  OF  WEIGHT  IN  LABOR  AND  DURING  LYING-IN.  Gassner 
states  that  the  body  increases  during  the  last  three  mouths  of  pregnancy 
about  one-thirteenth  of  the  entire  weight ;  this  increase  is  proportionally 
less  in  prirnipane  than  in  multipart ;  during  labor  a  woman  loses  one- 
ninth  of  that  she  had  at  the  end  of  pregnancy,  the  loss  being  chiefly 
due  to  the  expulsion  of  the  foetus  and  its  appendages  and  the  amnial 
liquor,  but  also  to  the  blood  lost  in  the  discharge  of  the  placenta,  to 
fecal  matter  expelled,  and  to  pulmonary  and  cutaneous  excretions. 
During  the  first  eight  days  of  lying-in  the  woman  loses1  one-eleventh, 
the  loss  resulting  from  the  lochial  discharge,  the  increased  action  of  the 
kidneys  and  the  skin,  and  the  mammary  secretion.  This  loss,  how- 
ever, is  not  so  great  if  a  good  diet  be  given,  as  the  statements  in  foot- 
note show.  Further,  Baumm,  in  Winckel's  clinic  at  Munich,  has 
proved  that  with  generous  food  the  loss  of  weight  is  about  one-fourth 
less  than  that  observed  by  Gassner.  The  total  weight  lost  in  labor  and 
in  the  puerperal  state  amounts  to  about  one-fifth  that  of  the  body.  At 
the  end  of  three  or  four  weeks  after  labor  the  loss  has  ceased,  and  gen- 
erally a  gain  begins. 

THE  SECRETION  OF  MiLK.2  During  the  latter  part  of  pregnancy 
and  immediately  after  labor  a  fluid  called  colostrum  is  found  in  the 
breasts,  and  often  spontaneously  exudes  or  can  be  pressed  from  the 
nipple ;  to  this  fluid,  as  found  in  the  cow  immediately  after  calving,  the 
name  of  biestings  is  given.  An  abundant  secretion  of  colostrum  in 
pregnancy  indicates  a  large  supply  of  milk.  Colostrum  differs  in  color, 
specific  gravity,  and  composition,  and  morphologically  from  milk.  It 
is  yellowish-white,  is  richer  in  fat  and  sugar  than  milk,  and  contains 
albumin  instead  of  casein;  it  has  a  larger  supply  of  salts  than  milk, 
and  hence,  according  to  most  authorities,  proves  a  laxative  to  the  new- 
born child,  assisting  in  carrying  oif  meconium  ;  but  this  excess  in  salts 
is  not  great,  and  it  is  more  rational  to  attribute  the  laxative  property  of 
the  fluid,  as  De  Sinety  does,  to  its  richness  in  glandular  elements,  which 
produce  indigestion.  The  following  is  Marchand's  statement  as  to  the 
composition  of  the  two  fluids  : 

In  100  parts  of  each — 

Colostrum.  Milk. 

Proteine  elements 17.20  1.90 

Lactine 630  5.30 

Butter 4.50  4.50 

Salts 0.25  0.18 

Water 71.63  81.12 

The  liquid  portion  of  milk  is  simply  a  transudation  from  the  blood, 
while  the  morphological  constituents  proceed  from  the  gland  cells. 
Colostrum  corpuscles  are  remarkable  for  their  size,  contain  fat  granula- 
tions, and  are  probably  detached  glandular  elements;  either  the  cell- 
wall  is  broken  down,  and  the  contents  set  free,  or,  as  De  Sin6ty  holds, 
the  cells  have  contractile  movements,  and  by  these  the  fatty  particles 
are  expelled.  These  minute  fat  granules  unite  together  to  form  larger 
masses  and  of  different  sizes ;  their  mixture  with  the  trausudatiou  from 

1  "  Klein wSchter,  however,  by  means  of  better  nourishment,  arrived  at  a  different  result ;  he 
noted  only  about  half  the  loss  of  weight  reported  by  Gassner,  and  Klemmer,  in  my  Dresden  clinic, 
by  means  of  meat  diet,  succeeded  in  obtaining  not  only  less  falliug-off  in  weight,  but  in  some  cases 
the  patient  gained  up  to  the  tenth  dav."    f  Winckel ) 

2  See  Fig.  151. 


MANAGEMENT  OF  THE  PUERPERAL  STATE.  343 

the  blood  makes  a  fine  emulsion,  and  this  is  milk.  The  casein  of  milk 
is  probably  formed  from  the  albumin  of  the  blood,  and  the  sugar  of 
milk  from  the  glucose. 

PHENOMENA  ASSOCIATED  WITH  THE  ESTABLISHMENT  OF  THE  SE- 
CRETION OF  MILK.  The  current  of  blood  which  has  been  flowing  to 
the  uterus  for  nine  months  now  turns  to  the  mammary  glands,  and  on 
the  second,  or  oftener  on  the  third  day,  these  organs  enlarge  and  their 
sensibility  increases ;  the  skin  covering  them  is  smooth  and  tense,  the 
nipples  are  less  prominent,  and  very  frequently  some  pain  is  felt  in  the 
axillary  glands ;  in  consequence  of  the  swollen  condition  of  the  breasts 
the  arms  cannot  be  brought  close  to  the  sides  of  the  chest.  The  general 
phenomena  attending  upon  the  beginning  of  the  milk  flow  are  restless- 
ness, thirst,  headache,  occasional  neuralgic  pains,  loss  of  appetite,  and 
possibly  slight  increase  in  temperature  and  in  the  frequency  of  the  pulse. 
But  that  which  the  old  authors  called  milk  fever  is  not  now  admitted ; 
in  very  rare  exceptions  decided  fever,  even  preceded  by  a  chill  and  last- 
ing twenty-four  hours,  has  been  observed  in  cases  in  which  no  compli- 
cation was  present,  but  the  almost  universal  rule  is  that  there  is  no  milk 
fever ;  as  Lorain  remarked,  it  is  a  vague  tradition  which  does  not  rest 
upon  classic  observation.  Siredey,  collecting  in  one  year  360  observa- 
tions as  to  changes  in  temperature,  states  he  can  assert  that  in  every  case 
in  which  the  temperature  in  the  axilla  exceeded  100.4°,  he  found  the  ex- 
planation of  the  febrile  movement  independent  of  the  lacteal  secretion. 

ChantreuiPs  investigation  led  him.  to  conclude  that  the  morbid  entity  called 
milk  fever  very  rarely  occurred ;  that  in  entirely  normal  cases  the  pulse  did  not 
rise  above  76,  and  consequently  there  could  be  no  question  about  fever,  and  that 
the  temperature  followed  the  variations  of  the  pulse.  In  normal  cases  the  tem- 
perature did  not  rise  during  the  secretion  of  milk  above  100.4°  or  100.2°,  figures 
which  have  been  adopted  as  expressing  the  mean  temperature  by  all  authors 
who  have  been  occupied  with  the  study  of  thermoinetry. 

The  secretion  of  milk  continues  from  8  to  12  mouths.  The  quan- 
tity increases  until  6  or  7  months,  and  decreases  from  the  8th  mouth. 
The  casein  increases  until  the  2d  month,  and  decreases  from  that  to  the 
9th,  and  so  also  the  butter ;  the  sugar  lessens  the  first  month,  then 
increases ;  the  salts  increase  the  first  five  months,  and  then  diminish.1 
If  the  woman  does  not  nurse,  the  milk  disappears  in  about  a  week. 
Menstruation  is,  as  a  rule,  absent  during  lactation,  but  ovulation  may 
occur,  and  it  is  not  uncommon  for  women  to  conceive  while  nursing  ; 
should  conception  occur,  the  supply  of  milk  lessens  and  finally  ceases. 

THE  MANAGEMENT  OF  CnrLDBED.  There  will  be  considered  under 
this  head  not  merely  the  care  of  the  mother,  but  also  that  of  the  child. 

ATTENTIONS  TO  THE  MOTHER.*     After  the  thorough  cleansing  of 

1  Zuelzer,  quoted  by  Kleinwachter. 

2  In  some  parts  of  the  world  it  appears  that  attentions  to  the  father  are  of  great  importance, 
thus — 

Peschel,  The  Races  of  Men,  pp.  24-25,  refers  to  paternal  lying-in  as  having  been  observed  by  in- 
habitants of  the  four  quarters  of  the  globe — in  Borneo,  for  example,  the  father  of  the  newborn 
child  is  for  eight  days  allowed  to  eat  nothing  but  rice,  must  take  care  not  to  expose  himself  to  the 
sun,  and  must  give  up  bathing  during  four  days  ;  and  states  such  coincidence  of  error  can  be  ex- 
plained in  one  or  the  other  of  only  two  ways — either  all  the  varieties  of  our  race  once  dwelt 
together  in  a  narrow  home  when  the  error  originated,  or  the  mental  faculties  of  all  these  families 
even  in  their  strongest  aberrations  are  the  same. 

The  significance  of  couvade,  or  male  childbed,  is  thus  given  by  Dr.  Poy,  of  Dublin,  in  the 
British  Medical  Journal,  September  26, 1891 :  The  writer  states  that  "  there  are  good  grounds  for 


344  PHYSIOLOGY  OF  THE  PUERPERAL  CONDITION. 

the  external  sexual  organs  by  a  warm  antiseptic  solution  and  a  similar 
injection  in  the  vagina,  the  necessary  care  of  injuries,1  if  any  have 
occurred,  and  proper  arranging  of  the  bed  and  body  clothing,  the 
patient  may  have  some  nourishment  if  she  desires,  and  should  have  if 
she  needs  it. 

REST.  In  the  great  majority  of  cases,  a  few  hours'  sleep  will  be 
the  most  important  restorative,  and,  therefore,  means  that  conduce  to 
this  end  should  be  used.  Generally  a  quiet  room  and  moderately  dark- 
ened will  be  all  that  is  required ;  but  in  some  cases  there  are  such  rest- 
lessness and  nervous  excitement  that  an  opiate  must  be  given.  So, 
too,  if  after-pains  are  so  severe  and  frequent  that  she  cannot  sleep,  and 
external  applications,  e.  g.,  of  cloths  wrung  out  of  hot  whiskey,  with 
compression  of  the  uterus,  fail  to  relieve,  opium  and  camphor,  or  auti- 
pyrine,  may  be  given  ;  quinine  in  a  dose  of  ten  grains  is  used  by  some 
practitioners. 

The  practice  which  old  obstetricians  had  of  preventing  a  woman's 
sleeping  during  the  first  hours  following  labor,  lest  flooding  might 
occur,  had  no  just  foundation  either  in  reason  or  in  experience. 

Of  course,  visitors  are  not  admitted,  and  if  the  baby's  cries  disturb 
the  mother  it  should  be  taken  for  a  few  hours  into  another  room.  She 
should  lie  the  first  few  hours  chiefly  upon  her  back,  and  then  occasion- 
ally upon  either  side,  for  it  is  better  she  should  not  be  restricted  to  one 
position. 

The  question  as  to  absolute  rest  in  bed  for  some  days  after  labor  is  not  a  new 
one.  Sydenham's  wise  observation  taught  him  that  of  those  who  died  after 
childbirth  the  result  in  the  great  majority  of  cases  was  from  getting  up  too  soon, 
and  he  said  he  did  "  not  suffer  a  woman  to  get  up  before  the  tenth  day."  That 
sagacious  and  successful  obstetric  practitioner,  the  late  Dr.  Churchill,  stated  that 
for  one  evil  result  from  an  error  in  diet  he  had  seen  ten  from  assuming  an  up- 
right position  or  leaving  the  bed  too  soon.  White,2  on  the  other  hand,  had  the 
puerpera  sit  up  in  bed  a  few  hours  after  delivery,  and  the  sooner  she  got  out  of 
bed  the  better ;  this  was  not  to  be  deferred  beyond  the  second  or  third  day. 
Goodell  had  the  patient  sit  up  the  day  after  labor,  while  her  bed  is  making ;  this 
sitting  up  is  repeated  once  or  twice  a  day,  until  the  fourth  or  fifth  day,  when 
she,  if  so  disposed,  gets  up  and  dresses  herself.  Solovieif 3  sustains  the  practice 
of  Goodell. 

Kunge,4  who  insists  upon  the  woman  remaining  in  bed  at  least  nine  days,  says 
that  in  the  first  two  days  she  should  be  upon  her  back,  and  then  cautious  move- 
ments and  the  side  position  are  permitted.  Sitting  in  bed,  for  example,  while 

the  conclusion  that  by  the  act  of  couvade  the  husband  accepts  the  paternity  of  the  child,  declares 
himself  its  author,  and  symbolizes  by  his  acts  that  his  conduct  is  directed  by  a  desire  for  its  pros- 
perity, and  the  attention  given  him  by  his  -rife  and  friends  is  an  acknowledgment  that  they  recog- 
nize his  claims  and  facilitate  his  design." 

1  The  following  statistics  of  one  of  the  residents  during  my  term  of  service  in  1889  are  here  in- 
troduced, having  been  omitted  in  their  more  appropriate  connection.  They  show  that  injuries  of 
the  perineum  in  childbirth  are  more  frequent  'than  practitioners  who  never  make  examinations 
after  labors  assert. 

PHILADELPHIA  HOSPITAL,  March  12, 1889. 

DEAR  DR.  PARVIN  :  I  am  very  happy  to  send  you  the  following  report  on  the  condition  of  the 
perineums  in  the  last  one  hundred  primiparse  and  last  one  hundred  multiparae  delivered  in  the 
maternity  department : 

Primiparse :    Perineum  intact,  58  Multiparse :    Perineum  intact.  84 

Lacerated,  41  Lacerated,  16 

Episiotomy,  1 

100  100 

Very  respectfully,  F.  W.  TALLEY. 

•  Treatise  on  the  Management  of  Pregnant  and  Lying-in  Women. 
8   Archives  de  Tocologie,  February,  1881. 

*  Lehrbuch  der  Geburtshulfe. 


MANAGEMENT  OF  THE  PUERPERAL  STATE.  345 

nursing,  eating,  and  urinating  is  positively  forbidden  during  the  first  five  or 
six  days. 

While  some  nurses  and  doctors  think  that  the  sooner  a  woman  after 
confinement  is  up  and  dressed,  apparently  well,  the  greater  their  credit, 
it  must  be  admitted  that  very  seriously  injurious  consequences  of  too 
early  getting  up  may  not  be  immediate  but  remote,  such  as  uterine  dis- 
placement or  subinvolution,  and  that  prolonged  rest  is  a  less  evil  than 
the  former ;  better  keep  a  woman  in  bed  a  week  too  long  than  have 
her  get  up  a  day  too  soon.  Again,  every  woman  is  a  law  unto  herself; 
one  may  convalesce  much  more  quickly  than  another,  and  uterine  invo- 
lution be  more  rapid.  The  condition  of  the  patient  is  a  better  criterion 
as  to  the  fitness  of  getting  up  than  the  number  of  days  after  labor ; 
so,  too,  the  effect  produced  by  being  up  ought  to  be  considered  in 
deciding  as  to  permitting  it  to  be  continued,  and,  therefore,  if,  for 
example,  the  woman  has  a  return  of  the  red  lochia,  or  if  abdominal 
pain  be  caused,  the  indication  is  very  plain  for  immediate  return  to 
bed.  It  is  probably  best  for  most  women  not  to  sit  up  out  of  bed  until 
ten  or  twelve  days  have  passed,  and  then  only  for  a  short  time,  though 
sitting  up  in  bed  while  taking  their  meals  may  be  permitted  in  most 
cases  after  the  third  day ;  it  is  better  for  the  puerpera  to  remain  in  her 
room  for  at  least  three  weeks. 

FOOD.  In  regard  to  this  question  the  most  diverse  opinions  have 
been  held.  Dionis  referred  to  the  popular  notion  of  his  day,  that  a 
woman  has  lost  so  much  blood  in  labor,  and  so  much,  too,  is  lost  by 
the  lochia,  she  ought  to  eat  more  abundantly  than  at  any  other  time,  in 
order  to  repair  the  loss,  and  condemned  it,  because  the  woman  was  in 
u  a  state  of  fever,"  and  the  fever  was  sure  to  come  on  the  second  or 
third  day.  Dewees  would  not  allow  any  animal  broth  until  after  the 
fifth  day,  or  any  animal  substance  until  after  the  fifteenth  ;  he  gave  for 
the  first  few  days  oatmeal  gruel,  tapioca,  sago,  mush  and  milk,  rice  and 
milk,  tea,  coffee,  or  very  thin  chocolate.  In  recent  years,  however, 
there  has  been  a  reaction  against  the  absolute  diet  once  insisted  upon  by 
obstetricians.  But  there  is  a  just  mean  between  famishing  and  feasting, 
between  restricted  and  generous  diet,  which  the  practitioner  will  best 
follow.  Those  who  have  seen  how  well  a  patient,  upon  whom  ovari- 
otomy has  been  performed,  gets  on  for  the  first  few  days  with  water, 
barley-water,  and  lime-water  and  milk,  will  hardly  believe  that  the 
puerpera  on  the  first  day  needs  either  chops  for  breakfast,  or  abundance 
of  roast  beef  for  dinner,  but  rather  that  she  will  convalesce  more  rapidly 
if  liquid  food  is  chiefly  given.  l  Indeed,  her  often  temporarily  enfeebled 
digestion  and  her  little  desire  for  solid  food  point  very  plainly  to  proper 
dietetic  practice ;  her  thirst  is  usually  much  greater  than  her  hunger. 
At  this  time  the  simpler  articles  of  food,  such  as  tea  and  toast,  the 
lighter  animal  broths,  milk  toast,  or  soft-boiled  eggs  will  be  most  accept- 
able ;  let  her  gradually  resume  her  usual  diet.  On  the  other  hand, 
there  are  women  whose  digestion  is  perfect,  and  whose  appetite  from 
the  first  craves  more  liberal  nourishment,  and  there  can  be  no  objection 
to  giving  them,  from  the  beginning,  the  more  easily  digested  animal 
foods.  Or  again,  there  may  be  a  patient  so  greatly  exhausted  that  beef- 
tea,  milk-punch,  or  eggnog  must  be  given  at  frequent  intervals.  There- 


346  PHYSIOLOGY  OF  THE  PUERPERAL  CONDITION. 

fore,  no  absolute  rule  as  to  the  diet  of  the  first  days  can  be  given  ;  each 
case  must  be  judged  by  itself,  and  the  food  directed  according  to  the 
condition.  Cold  water  will  usually  be  found  the  most  acceptable  drink, 
and  can  be  given  at  frequent  intervals.  If,  however,  the  secretion  of 
milk  l>e  too  abundant,  it  can  be  diminished  by  lessening  the  quantity  of 
fluids  taken,  and  under  these  circumstances  it  is  well  to  have  the  patient 
quench  her  thirst  by  pieces  of  ice  rather  than  by  copious  draughts  of 
water  or  of  other  fluid. 

THE  CONDITION  OF  THE  BLADDER.  The  puerpera  should  be 
directed  to  empty  the  bladder  twelve  hours  after  delivery,  for  unless  so 
advised  she  may  be  unconscious  of  the  accumulation  of  urine,  and  it 
may  continue  until  the  organ  is  so  greatly  distended  that  spontaneous 
evacuation  is  impossible,  even  in  case  there  be  no  obstruction  of  the 
urethra  from  swelling.  If  urine  is  not  passed  within  twenty-four  hours, 
the  catheter 'must  be  used,  and  its  use  repeated  in  from  eight  to  twelve 
hours  until  the  patient  recovers  the  lost  power ;  the  instrument  must 
be  carefully  disinfected  before  and  after  use,  and  the  parts  adjacent  to 
the  urethral  orifice  washed  with  an  antiseptic  solution,  e.  g.,  5  per  cent, 
solution  of  carbolic  acid,  before  the  instrument  is  introduced,  for  a 
cystitis  may  result  from  neglect  of  these  precautions  ;  in  some  instances 
the  inflammation  passes  from  the  bladder  to  the  ureter  and  the  kidney. 
In  order  to  run  no  risk  of  carrying  from  the  external  genitals  septic 
matter  into  the  bladder,  it  is  advised  by  some  to  trust  to  sight  and  not 
to  touch  in  catheterizatiou ;  but  unless  the  nurse  uses  the  instrument, 
this  is  not  expedient.  In  some  instances  there  is  dribbling  of  urine 
from  a  very  full  bladder,  and  both  the  patient  and  nurse  insist  that  the 
organ  is  completely  emptied  when  in  fact  it  contains  a  large  amount' of 
urine ;  in  all  doubtful  cases  the  practitioner  should  carefully  palpate  the 
abdomen,  and  if  doubt  remains  remove  it  by  introducing  the  catheter. 
By  abstaining  from  the  use  of  the  catheter,  unless  the  indications  are 
plain — a  distended  bladder  and  suffering,  and  inability  to  empty  it,  not- 
withstanding external  applications  and  moderate  pressure — we  have  the 
best  prophylactic  of  puerperal  cystitis.1 

CONDITION  OF  THE  BOWELS.  On  the  third  or  fourth  day  a  free 
alvine  evacuation  is  to  be  had  either  by  a  warm-water  enema,  by  a  dose 
of  calcined  magnesia,  by  Rochelle  salts,  a  Seidlitz  powder,  liquid  citrate 
of  magnesia,  one  of  the  mineral  waters,  as  Hunyadi  Janos,  or  by  castor 
oil,  which  remains,  notwithstanding  all  prejudices  and  reproaches,  one  of 
the  safest  and  most  certain  laxatives  for  the  puerperal  woman.  In  case 
she  does  not  nurse  her  infant  a  saline  is  preferred,  as  the  watery  opera- 
tion to  some  extent  lessens  the  determination  of  blood  to  the  mammary 
glands.  After  the  first  free  evacuation  the  bowels  should  be  moved 
every  day,  or  every  other  day. 

THE  LOCHIA.  CARE  OF  THE  EXTERNAL  GENITALS.  VAGINAL 
INJECTIONS,  ETC,  Napkins  or  antiseptic  pads  are  usually  applied  to  re- 
ceive the  lochial  flow ;  if  the  former,  they  should  be  sprinkled  with  a  warm 
antiseptic  solution  before  application,  or  absorbent  cotton,  prepared  as 
has  been  stated,  may  conveniently  replace  the  latter.  Kaltenbach  advises 

1  Schatz,  of  Rostock,  advocates  in  ischuria  which  persists  in  lying-in  women,  dilatation  of  the 
urethra  to  an  extent  admitting  the  little  finger— rarely,  a  second  dilatation  is  necessary. 


MANAGEMENT  OF  THE  PUERPERAL  STATE.  347 

either  cotton  or  jute,  which  after  use  may  be  hurued.  During  the  first 
week  the  external  genital  organs  are  to  be  bathed  twice  a  day  with  a  warm 
antiseptic  solution,  e.  g.,  1-2  per  cent,  creolin  mixture  in  water,  and  if 
there  be  the  least  offensive  odor  of  the  lochia  a  similar  solution  should 
be  injected  in  the  vagina  twice  or  oftener  in  twenty-four  hours ;  but 
unless  there  be  this  indication  vaginal  injections  are  not  given.  Raw 
surfaces  at  the  vaginal  entrance  or  upon  the  external  genitals  are  to  be 
carefully  and  gently  washed  twice  a  day  with  the  creoliu  mixture,  and 
then  they  may  be  dusted  either  with  iodoform  or  with  one  part  of  sali- 
cylic acid  and  ten  of  starch.  Sponges  should  not  be  used  in  bathing, 
but  absorbent  cotton  or  perfectly  clean  cloths,  the  cotton  or  cloths  being 
afterward  burned.  The  temperature  of  the  room  should  be  from  60° 
to  65°;  the  room  must  be  well  ventilated,  but  the  patient  is  to  be  pro- 
tected from  drafts  of  cold  air ;  all  soiled  clothing,  napkins,  etc.,  and 
urinary  or  fecal  evacuations  must  be  promptly  removed  so  as  not  to 
poison  the  air  by  their  exhalations.  While  care  is  taken  that  the  pa- 
tient is  not  chilled,  the  active  state  of  her  skin  making  her  peculiarly 
susceptible  to  any  sudden  reduction  of  temperature,  she  ought  not  to 
be  so  carefully  and  heavily  covered  with  bed-clothing  as  to  make  her 
uncomfortable  and  increase  the  perspiration.  The  room  is  generally 
kept  moderately  darkened,  in  the  interest  of  the  mother  to  promote  her 
rest,  and  in  that  of  the  child  to  prevent  the  supposed  injurious  effect  of 
light  upon  its  eyes. 

Changes  in  the  clothing  of  the  puerpera  are  made  from  day  to  day  as 
cleanliness  and  comfort  require ;  it  is  important  that  all  clothing,  and 
especially  garments  that  come  in  direct  contact  with  the  skin,  be  dry 
and  warm,  though  few  would  direct  the  method  to  secure  this  end 
advised  by  Hubert.1  The  exclusion  of  visitors  during  the  first  week 
materially  assists  in  the  convalescence  of  the  patient. 

LACTATION.  Moralists  and  obstetricians  agree  in  urging  the  impor- 
tance of  the  mother  nursing  her  infant.2  As  a  rule,  she  thus  best  secures 
her  own  and  its  health,  she  obejs  nature's  law  and  design,  promotes  the 
closest  mutual  attachment,  and  has  an  important  influence  in  fashioning 
the  first  mental  and  moral  development  of  her  offspring.  The  preva- 
lence of  wet-nursing  has  been  said  to  be  the  proof  of  a  people's  decline. 
Maternal  nursing  was  once  held  in  such  high  honor  by  some  of  the 
Romans  that  it  appears  no  greater  praise  could  be  inscribed  upon  a 

1  Hubert  says  that  the  chemise  should  be  worn  a  day  by  the  mother  or  the  sister,  or  placed  dur- 
ing a  night  in  the  husband's  bed,  before  she  wears  it.    Upon  the  page  containing  this  suggestion 
he  narrates  from  Djonis  the  well-known  story  in  regard  to  Clement  using  for  the  dauphiness  after 
her  first  labor  the  fleece  of  a  black  sheep,  this  fleece  being  placed  jusc  after  its  removal  from  the 
living  animal  upon  the  naked  abdomen  of  the  puerpera,  and  his  not  using  it  in  her  subsequent 
confinements.    The  butcher  brought  the  fleece  carefully  folded  in  his  apron  to  the  bedside  of  the 
patient,  but  unfortunately  had  left  the  door  open,  and  the  fleeceless  sheep,  bleating  and  bloody, 
followed  him,  greatly  to  the  consternation  of  the  dauphiness  and  of  the  ladies  present ;  this  acci- 
dent prevented  the  repetition  of  the  remedy.    Clement's  and  Hubert's  practice  may  be  placed 
side  by  side. 

Another  curious  fact  is  related  by  Dionis  which  shows  that  a  medical  sect  of  the  present  day  have 
at  least  an  illustrious  example  in  the  belief  that  odors,  as  flowers,  have  an  unfavorable  effect  upon 
the  sick.  "  It  is  claimed  that  odors  have  a  very  injurious  influence  at  this  time ;  and  persons  who 
are  perfumed  are  not  allowed  to  enter  the  room  or  princesses  or  of  ladies  of  rank.  In  the  case  of 
the  dauphiness,  the  usher  had  orders  to  examine  the  ladies  who  came,  and  to  send  away  any  who 
were  perfumed  or  had  flowers."  Traite  General  des  Accouchements,  1718. 

2  The  late  Mr.  Darwin,  in  his  Descent  of  Man,  suggests  the  probability  that  during  "  a  former 
prolonged  period  male  mammals  aided  the  females  in  nursing  their  offspring,  and  that  after- 
'ward  from  some  cause,  as  from  a  smaller  number  of  young  being  produced,  the  males  ceased  giv- 
ing this  aid  ;  disuse  of  the  organs  during  maturity  wo'uld  lead  to  their  becoming  inactive." 


348  PHYSIOLOGY  OF  THE  PUERPERAL  CONDITION. 

mother's  tomb  than  that  found,  according  to  Hubert,  upon  the  tombs  of 
many  women  dying  in  Hadrian's  time:  Filios  suos  propriia  uberibus 
educavit. 

In  the  Spectator,  No.  246,  there  will  be  found  an  excellent  article  by  the  cele- 
brated essayist,  Steele,  advocating  maternal  nursing.  So,  too,  in  Richardson's 
Pamela  there  is  a  valuable  discussion  of  the  subject.  Surely,  argument  upon 
this  theme  is  better  than  the  Zolaism  which  infects  so  many  novels  now-a-days, 
and  which  even  enters  medical  literature  with  needless  pictures  of  woman's 
external  sexual  organs  and  her  nude  form,  and  such  exhibitions  are  almost  as 
odious  as  the  egoism  which  parades  upon  every  occasion,  and  without  occasion, 
the  photograph  of  the  doctor ! 

OBSTACLES  TO  THE  MOTHER'S  NURSING.  Nevertheless  there  may 
be  circumstances  or  obstacles  arise  which  will  forbid  the  mother  nurs- 
ing. First.  The  child  may  be  illegitimate,  and  the  mother,  to  hide  her 
shame  or  to  save  it  from  disgrace,  must  part,  with  it.  Nevertheless  it  is 
better  to  nurse  it  during  the  first  few  weeks.  Second.  The  poor  quality 
or  scanty  secretion  of  milk  may  discourage  the  mother  from  nursing. 
But  means  may  be  used  to  increase  the  secretion  and  to  improve  the 
quality  of  the  milk ;  and,  at  any  rate,  mixed,  nursing  is  better  than  a 
diet  exclusively  of  artificial  food — that  is,  let  the  child  get  all  it  can  from 
the  mother,  then  make  up  the  deficiency  by  artificial  food.  Third. 
Vices  of  conformation  of  the  nipple,  or  changes  in  the  structure  of  the 
gland,  the  latter  generally  resulting  from  inflammation  in  a  previous 
confinement,  may  render  lactation  difficult  or  impossible.  Fourth.  Dis- 
eases of  the  mother  which  are  aggravated  by  nursing,  or  will  injure  the 
infant  through  the  milk,  forbid  her  nursing.  Thus  if  the  mother  be 
exhausted  by  anaemia,  or  if  she  be  suffering  from  phthisis,  she  ought  not 
to  nurse;  indeed,  a  marked  predisposition  to  the  latter  is  a  reason  for 
not  nursing,  since  the  statistics  of  Flint  show  that  in  13.5  per  cent,  of 
married  women  under  forty  years  who  are  phthisical  the  disease  is  de- 
veloped during  lactation.  If  syphilis  be  recent,  the  mother  should  not 
nurse,  for  then  the  probability  is  the  child  is  not  infected ;  but  other- 
wise, that  is,  if  the  mother  was  syphilitic  when  she  conceived,  or  acquired 
the  disease  in  the  first  half  of  pregnancy,  she  may.  It  is  criminal  to 
employ  a  wet-nurse  for  a  syphilitic  child. 

As  far  as  the  infant  is  concerned,  it  may  have  been  born  prematurely, 
and  be  so  feeble  it  cannot  nurse  at  first ;  or  it  may  be  so  deformed — as, 
for  example,  by  harelip — or  it  may  have  been  so  injured  in  natural  or  in 
artificial  delivery  that  it  is  unable  to  do  so.  In  some  cases  the  disability 
is  only  temporary. 

TREATMENT  IF  MOTHER  DOES  NOT  NURSE.  If  a  woman  is  not  to 
nurse,  let  her  have  a  less  liberal  diet  until  the  secretion  of  milk  disap- 
pears, and  until  then,  too,  a  saline  laxative  may  be  given  each  day,  be- 
ginning with  the  third;  the  breasts  are  covered  with  a  layer  of  cotton- 
batting,  which  is  to  be  frequently  changed  as  it  becomes  wet  with  the 
mammary  secretion  or  with  that  of  the  sudoriparous  glands  ;  in  this,  as 
well  as  in  other  cases,  the  gland  may  be  supported  when  greatly  enlarged 
by  a  properly  applied  handkerchief,  the  ends  of  which  are  tied  over  the 
opposite  shoulder.  Various  popular  as  well  as  professional  remedies 
have  been  recommended  to  stop  the  secretion  of  milk ;  among  the  former 


MANAGEMENT  OF  THE  PUERPERAL  STATE.  349 

may  be  mentioned  a  piece  of  flannel  saturated  with  spirits  of  camphor 
applied  to  each  breast,  and  among  the  latter  iodide  of  potassium  intern- 
ally and  belladonna  locally.  Generally  all  local  treatment,  except  that 
which  comforts  the  patient,  is  unnecessary,  as  the  secretion  stops  if  the 
milk  is  not  required,  for  the  great  law  of  political  economy  is  as  true 
here  as  in  the  department  of  manufactures — if  there  is  no  demand,  there 
will  be  no  supply — and  possibly  some  if  not  all  the  remedies  advised  to 
arrest  the  secretion  have  no  more  virtue  than  one  which  Mauriceau1 
mentioned  as  being  employed  in  his  day. 

If  the  breasts  are  greatly  increased  in  size,  the  application  of  a  band- 
age is  important ;  it  contributes  to  the  patient's  comfort,  and  in  lessen- 
ing the  supply  of  blood  by  compressing  the  breasts,  of  course  diminishes 
the  secretion  of  milk. 

CARE  OF  THE  BREASTS  IN  NURSIXG.  In  case  the  mother  is  to  nurse, 
the  child  is  not  put  to  the  breast  until  twelve  hours  after  labor.  Some 
advise  the  first  application  to  be  made  as  soon  after  delivery  as  the 
woman  has  had  the  necessary  attentions,  while  others  would  wait  until 
the  secretion  of  milk  is  established,  alleging  that  an  earlier  application 
is  vain  in  securing  nourishment,  that  it  wearies  the  mother  and  renders 
her  more  liable  to  sore  nipples.  Immediate  application  is  to  be  rejected 
because  the  mother  is  so  fatigued  and  needs  rest,  and  a  late  one  because 
of  the  difficulty  of  the  child's  nursing  then,  from  the  breast  being  so 
swelled  that  the  nipple  cannot  be  readily  seized  by  it.  While  it  is  true 
that  the  infant  gets  little  nourishment  during  the  first  twenty-four  or 
forty-eight  hours,  yet  it  does  get  the  colostrum  which  nature  seems  to 
have  designed  as  a  suitable  laxative ;  moreover,  it  is  usually  satisfied 
with  it,  and  is  saved  from  having  its  stomach  filled  with  improper  food. 
It  is  probable,  too,  that  the  early  and  frequent  removal  of  the  con- 
tents of  the  breasts  not  only  secures  a  proper  formation  or  drawing  out 
of  the  nipple,  but  also  leads  to  a  gradual  secretion  of  the  milk,  and  thus 
local  and  constitutional  disturbances  from  this  cause  are  prevented.  Cer- 
tainly, if  we  follow  the  rule  observed  by  the  young  of  inferior  mam- 
mals, the  child  will  be  put  to  the  breast  within  a  few  hours  after  birth  : 
but  the  rule  of  twelve  hours,  as  given  above,  is  better. 

The  breasts  are  carefully  protected  from  cold  by  covering  them  with 
soft  flannel  or  linen,  which  much  be  changed  when  it  becomes  moist. 
The  infant,  as  a  rule,  should  not  be  applied  to  each  breast  at  one  nurs- 
ing, but  to  them  alternately,  thus  giving  the  nipples  as  long  a  rest  as 
possible  between  the  times  of  nursing,  until  liability  to  inflammation 
has  passed.  The  infant  must  got  be  allowed  to  sleep  with  the  nipple 
in  its  mouth,  for  then  it  sleeps  and  sucks  alternately,  and  its  digestive 
organs,  kept  in  almost  constant  exercise,  are  liable  to  become  disordered  ; 
this  practice  is  very  fatiguing  to  the  mother,  and  the  nipple  being  kept 
constantly  moist  and  heated,  softening  and  desquamation  of  the  epi- 
dermis follow,  with  consequent  erosions  and  fissures  of  the  nipple,  and 
thus  the  doors  are  opened  for  the  entrance  of  germs,  causing,  finally, 
inflammation  of  the  breast. 

1  "  I  know  some  women  who  held  it  for  a  very  great  secret,  and  most  certain  to  drive  the  milk 
effectually  back — and  that  is,  to  put  on  her  husband's  shirt  yet  warm,  immediately  after  lie  had 
taken  it  off,  and  wear  it  until  the  milk  be  gone."  (Op.  cit.)  Of  course,  the  value  of  the  remedy  is 
indicated  in  the  last  words,  "  wear  it  until  the  inilk  be  gone." 


350  PHYSIOLOGY  OF  THE  PUERPERAL  CONDITION. 

Before  aiid  after  each  nursing  the  nipple  as  well  as  the  mouth  of 
the  child  should  be  washed  with  clean  water,  and  twice  a  day  a  little 
cocoa  butter  may  be  applied  to  the  former ;  if  it  becomes  sensitive, 
and  especially  if  the  slightest  rawness  or  excoriation1  appears,  the 
surface  may  be  pencilled  once  or  twice  a  day  with  compound  tincture 
of  benzoin  ;  if  this  treatment  does  not  suffice,  there  may  be  conjoined 
with  it,  lightly  touching  the  tender  surface,  a  twenty-grain  solution 
of  nitrate  of  silver,  and  the  use  of  a  nipple-shield — the  best  is  Need- 
ham's  ;  after  the  application  of  the  tincture  of  benzoin  the  nipple  is  left 
exposed  until  the  tincture  dries,  and  especially  there  must  be  no  lint  or 
a  rag  placed  upon  the  surface,  which  of  course  can  be  removed  only 
with  the  greatest  difficulty  at  the  next  nursing. 

Boric  acid  in  a  3  per  cent,  solution  has  been  employed  as  a  lotion, 
and  also  used  for  saturating  compresses  laid  upon  the  nipple  in  order  to 
prevent  mammary  inflammation  ;  the  success  was  certainly  great.  A 
very  weak  solution  of  corrosive  sublimate,  as  advised  by  Tarnier,  has 
also  been  employed  with  somewhat  greater  success.2 

During  the  first  two  or  three  days  the  infant,  if  comfortable,  sleeps 
almost  all  the  time,  and  once  in  five  or  six  hours  is  as  'often  as  it  needs 
to  nurse ;  with  the  perfect  secretion  of  milk  the  intervals  must  be 
shortened  to  two  or  three  hours,  endeavoring,  however,  to  have  the 
child  nursed  only  twice  in  the  night,  so  as  to  secure  the  mother  as  long 
periods  as  possible  of  uninterrupted  rest.  The  infant  ought  to  get  an 
ample  supply  from  nursing  fifteen  to  twenty  minutes ;  if  it  continue 
nursing  longer,  there  is  almost  certainly  insufficient  secretion  of  milk. 

AGALACTIA.  If  the  milk  be  scanty,  it  may  in  many  cases  be  increased 
by  giving  the  patient  a  liberal  diet,3  especially  by  having  her  take  ani- 
mal broths,  chocolate,  and  milk  freely ;  if  the  last  can  be  drunk  at  the 
temperature  it  is  furnished  by  nature,  it  is  best ;  some  women  find  that 
malt  liquors  increase  the  flow  of  milk  when  all  other  means  have  failed, 
and  only  under  those  circumstances  may  they  be  advised. 

Various  galactagogues  have  been  recommended,  such  as  the  leaves  of  the 
castor-oil  plant  applied  to  the  breast,  and  drinking  certain  vegetable  infusions, 
as  of  anise  and  of  fennel ;  faradization  of  the  breasts  has  in  some  cases  produced 
remarkably  beneficial  results.  Kaltenbach  says  that  the  laity  attach  great 
importance  to  the  so-called  milk-powder:  Pulv.  sem.  fcenicul.,  cort.  aurant., 
sacch.  alb.  aa.  g.  2,  magnes.  ca'rb.  g.  4.  But  these  are  not  to  be  compared  with 
suitable  and  sufficient  food  conjoined  with  regular  rest  and  as  entire  freedom 
from  care  as  possible,  the  use  of  moderate  but  not  fatiguing  exercise  in  the  open 
air,  and  avoidance  of  anxiety ;  mental  worry,  bodily  fatigue,  and  loss  of  sleep 
notably  lessen  the  supply  of  milk. 

GALACTORRHCEA.  Galactorrhoea  may  occur  when  there  is  polyga- 
lactia  or  excessive  secretion  of  milk,  and  also  when  the  secretion  is 
normal  in  amount.  As  usually  seen  in  the  puerpera  it  is  the  former 
variety  of  the  disorder,  is  only  temporary,  and  generally  yields  to  mod- 
erate compression  of  the  mammae,  a  restricted  diet,  and  saline  laxatives. 

De  Sine'ty  refers  to  cases  in  which  the  supply  of  milk  is  so  abundant  that  sev- 
eral infants  could  be  nursed,  and  weaning  does  not  arrest  the  exuberance.  Very 

1  At  the  maternity,  Brussels,  Hagermann  advises  in  excoriation  or  fissures  of  the  nipple  1  part 
each  of  tincture  of  benzoin  and  of  balsam  of  Peru,  and  8  parts  of  simple  cerate. 

-  See  Pingat's  monograph,  De  la  prophylaxie  des  abces  du  sein. 

3  An  objection  has  recently  been  made  to  milk,  on  the  ground  that  it  acts  as  a  diuretic,  and  does 
not  increase  the  mammary  secretion. 


MANAGEMENT  OF  THE  PUERPERAL  STATE.  351 

great  inconvenience  results  from  this  condition,  for  the  breasts  are  painful  and 
the  constantly  flowing  milk  requires  several  napkins  a  day  for  its  absorption ; 
finally  the  subject  may  become  exhausted  by  the  discharge,  a  condition  formerly 
called  tabes  lactea  resulting.  Marvellous  stories  have  been  reported,  especially 
by  Puzos,1  as  to  the  abundance  of  the  secretion  of  milk.  Borelli  stated  that  a 
nurse  had  so  great  a  supply  she  not  only  suckled  two  infants,  but  sold  a  large 
quantity  to  an  apothecary  who  from  it  made  butter  for  the  phthisical.  Ridley, 
a  physician,  said  of  his  wife  that  she  nursed  twins,  several  small  puppies,  and 
then  had  enough  milk  escape  from  her  breasts  in  twenty-four  hours  to  make  a 
pound  and  a  half  of  butter.2 

DIAGNOSIS  OF  RECENT  DELIVERY.  Very  important  questions  in  medical 
jurisprudence  may  arise  in  connection  with  childbirth.  One  of  these  relates  to 
the  evidence  of  recent  delivery.  If  a  priinipara,  the  fragments  of  the  torn 
hymen  will  be  visible  at  the  entrance  of  the  vagina ;  the  frsenulum  will  almost 
invariably  be  found  torn,  and  very  probably  more  extensive  injury  to  the  peri- 
neum ;  the  external  genital  organs  are  swelled,  red,  sensitive  to  the  touch,  and 
show  various  recent  injuries ;  there  is  a  bloody  discharge  from  the  vagina,  and 
this  organ  will  have  injuries  involving  its  mucous  membrane,  its  rugae  are  absent, 
and  its  calibre  is  so  much  increased  that  the  hand  can  be  introduced.  In  multi- 
parse  all  these  signs  may  be  wanting  except  the  discharge  and  the  capaciousness 
of  the  vagina,  and  the  absence  of  rugse,  though  there  will  be  almost  always 
swelling  and  redness  of  the  external  genitals.  The  uterus  is  a  round,  hard  body, 
readily  felt  by  abdominal  palpation ;  the  abdominal  wall  has  its  central  line  of 
pigmentation,  and  laterally  the  bluish  cicatrices  of  pregnancy  may  be  seen, 
while  if  the  woman  be  a  multipara  white  cicatrices  are  usually  found.  The  breasts 
are  swelled,  the  areola  discolored,  and  colostrum  or  milk  may  be  pressed  out  of 
the  nipple.  After  seven  or  eight  days  external  injuries  of  the  genitals  will  be 
healed,  but  the  lochial  discharge  remains,  and  the  characteristic  striae  and  the 
pigmentation  may  be  observed  upon  the  abdomen  and  the  breast;  the  uterus 
will  be  found  enlarged.  Korrnann  states  that  after  the  third  week  the  question 
of  recent  delivery  can  hardly  be  answered  with  certainty.  When  the  delivery 
was  premature  the  difficulty  increases  with  the  length  of  time  that  may  have  in- 
tervened before  the  completion  of  pregnancy,  and  if  there  are  no  external 
injuries  the  diagnosis  will  chiefly  rest  upon  the  lochial  discharge  and  upon  the 
increased  size  of  the  uterus. 

May  the  second  stage  of  labor  be  so  rapid  in  its  progress  or  so  sudden  in  its 
termination  that  a  woman  is  taken  by  surprise,  as  it  were,  so  that  she  cannot  lie 
down  upon  the  bed  or  on  the  floor,  and  the  child,  born  while  she  is  standing, 
falls  on  the  floor,  receiving  serious  or  fatal  injury  ?  Kleinwachter's  answer  is, 
that  it  may  happen  with  a  multipara  whose  soft  parts  are  greatly  relaxed  and 
offer  little  resistance,  the  labor-pains  very  strong,  the  basin  of  normal  width,  or 
somewhat  greater,  and  the  foetus  of  the  usual  size  ;  for  several  cases  of  this  acci- 
dent in  which  there  was  no  question  of  medical  jurisprudence  involved  have 
occurred.  He  regards  it,  however,  as  hardly  possible  in  the  case  of  a  primipara. 
Yet  it  may  be  conceived  as  not  impossible  that  a  primipara  alone,  or  without 
any  intelligent  person  being  present,  may  be  deceived  by  the  factitious  desire  to 
empty  the  rectum  when  the  child's  head  is  very  low  down,  causing  her  to  leave 
the  bed  for  the  water-closet,  and  the  child  being  born  there  perish  for  want  ot 
proper  immediate  attention.  Again :  May  a  woman  give  birth  to  her  child  while 
she  is  in  bed,  and  she  be  in  such  condition  that  the  child  perishes  for  want  of 
proper  attention,  smothered  it  may  be  by  the  bed-clothes  or  in  consequence  of 
its  face  falling  directly  into  a  pool  of  liquid  between  the  mother's  thighs  ?  The 
answer  generally  made  to  this  question  is  that  such  an  event  may  happen  in  the 
case  of  a  primipara,  but  not  in  that  of  a  multipara.  Yet  it  would  be  going  too 
far  to  say  that  while  exceedingly  improbable  in  the  case  of  the  latter,  it  is  neces- 
sarily impossible. 

ATTENTIONS  TO  THE  CHILD.     The  care  of  the  infant  immediately 
after  birth  in  case  it  should  be  in  a  normal  condition  has  been  considered. 

1  Traite  des  Accouchmens.     Paris,  1759. 

2  It  would  appear  from  these  Illustrations  that  it  is  possible  for  a  wet-nurse,  contrary  to  the 
opinion  expressed  in  a  recent  poem,  "  Glenaveril,"  to  be  a  table  d'hote. 


352 


PHYSIOLOGY  OF  THE  PUERPERAL  CONDITION. 


But  if  labor  be  premature  or  from  other  cause  the  infant  is  very  feeble, 
it  may  be  necessary  to  postpone  the  washing  and  dressing,  and  simply 
wrap  it  in  warm  cotton  and  surround  it  by  bottles  of  hot  water,  or  use 
other  means  to  secure  for  it  a  normal  temperature ;  it  is  then  too  feeble 
to  suck,  and  must  be  fed  with  milk  from  the  mother's  breast  for  some 
days. 

The  results  which  have  been  attained  in  Paris  by  means  of  the  couveuse  and 
gavaye  in  prematurely  born  infants  are  very  remarkable.  By  these  30  per  cent, 
of  children  born  at  six  months  have  been  saved,  63.6  per  cent,  of  those  born  at 
seven,  and  85  7  per  cent,  of  those  born  at  eight  months.  The  couveuse,  or  incu- 
bator, will  rarely  be  used  outside  of  maternities ;  its  purpose  being  to  secure  for 
the  infant  a  uniform  temperature  of  85°-95°  F.,  this  end  must  be  obtained  in 
private  practice  by  the  means  previously  suggested.  But  gavage  is  available  to 
the  practitioner.  The  apparatus  used  by  Tarnier  is  shown  in  the  subjoined  illus- 
tration. The  practitioner  can  easily  improvise  a  simpler  apparatus ;  all  he  needs 
is  a  small  glass  funnel  to  which  a  rubber  tube  is  attached— the  red  rubber  cathe- 

FIG.  153. 


'ft/ 
50 

—40 

—  30 

• 

] 

TARNIER'S  APPARATUS  FOR  THE  ARTIFICIAL  FEEDING  OF  PREMATURE  OR  FEEBLE  INFANTS 
(GAVAGE)  ;  LUER'S  MODEL. 

ter  is  advised.  The  food  being  ready,  preferably  milk  from  the  mother's  breast, 
the  infant  is  placed,  with  its  head  slightly  raised,  upon  the  knees  of  the  nurse ; 
the  free  end  of  the  tube  is  moistened,  then  passed  to  the  base  of  the  tongue,  and 
the  infant  by  the  instinctive  efforts  at  swallowing  will  carry  it  to  the  entrance  of 
the  oesophagus,  when  the  nurse  by  gentle  pressure  pushes  the" end  into  the  stomach ; 
the  distance  is  about  six  inches  from  the  part  which  enters  the  mouth  to  that 
which  is  in  the  stomach.  The  milk  is  now  poured  into  the  funnel,  or  receiver, 
and  gravity  quickly  carries  it  through  the  tube  into  the  stomach ;  the  tube  must 
be  promptly  withdrawn  after  the  funnel  is  empty,  lest  the  child  vomit.  The 


MANAGEMENT  OF  THE  PUERPERAL  STATE.  353 

quantity  and  the  frequency  of  the  feedings  will  depend  upon  the  age  and  strength 
of  the  infant.  A  very  feeble  infant,  born  some  time  before  the  end  of  pregnancy, 
must  be  fed  every  hour,  and  between  two  and  three  teaspoonfuls  of  milk  given  at 
each  meal.  (This  description  has  been  condensed  from  Tarnier's  directions.) 

DISCHARGES  FROM  THE  BLADDER  AND  BOWELS.  Some  time  in  the 
first  twelve  hours  the  infant  usually  urinates.  The  urine  during  the 
first  few  days  has  a  low  specific  gravity,  and  is  quite  pale.  Apparent 
retention  is  generally  non-secretion  ;  for  when  the  infant  takes  little  or 
no  food  the  quantity  of  urine  secreted  is  necessarily  very  small.  If 
there  be  actual  retention  and  no  urethral  obstruction,  a  warm  bath,  fol- 
lowed by  the  application  of  cloths  wrung  out  of  warm  vinegar  to  the 
hypogastrium,  has  been  recommended  ;  the  use  of  the  catheter  is  very 
rarely  necessary.  Meconium,  so  named  from  its  resemblance  to  the 
juice  of  the  poppy,  is  usually  passed  a  few  hours  after  birth ;  but  if  the 
anus  be  not  imperforate,  a  delay  of  a  day  or  two  in  this  evacuation  need 
give  no  anxiety  ;  in  case  of  longer  delay  a  simple  enema  of  warm  water 
or  of  flaxseed  tea  may  be  used,  or  a  little  sweet  oil  given  by  the  mouth. 
The  third  or  fourth  day  the  meconiura  usually  disappears  from  the 
stools,  and  these  gradually  become  a  light  canary-yellow. 

THE  UMBILICAL  CORD.  In  three-fourths  of  infants  born  at  term 
the  stump  of  the  umbilical  cord  falls  off  within  five  days,  but  in  prema- 
ture infants  the  time  is  longer. 

Ahlfeld  has  recently  employed  secondary  section  of  the  navel  cord,  and  the 
prevention  of  disease  of  the  navel  and  adjacent  parts  he  believes  is  thereby 
secured.  His  method  is,  the  third  or  fourth  day  after  birth,  to  cut  off  the  stump 
of  the  cord,  it  previously  having  been  disinfected ;  the  cut  surface  is  sprinkled 
with  boric  acid. 

The  raw  surface  left  by  the  detachment  of  the  cord  does  not  cicatrize 
for  eight  or  ten  days ;  it  may  be  washed  daily  with  carbolized  water, 
and  afterward  a  carbolized  ointment  applied,  or  it  may  be  dusted  with 
calomel  or  with  a  simple  absorbent  powder. 

UMBILICAL  HEMORRHAGE  OR  OMPHALORRHAGIA.  It  has  some- 
times happened  that  a  woman  has  given  birth  to  her  child  while  stand- 
ing, and  the  infant  falling  to  the  floor  the  cord  has  been  torn,  or  a 
similar  tearing  has  occurred  in  forceps  delivery,  the  cord  being  abnor- 
mally short,  and  in  either  case  more  or  less  serious  hemorrhage  may 
follow.  But  the  most  frequent  variety  of  umbilical  hemorrhage  ob- 
served is  that  which  may  happen  several  days  after  the  birth  and  sub- 
sequent to  the  detachment  of  the  cord.  In  forty-one  cases  collected 
by  Miuot1  the  average  time  was  eight  days ;  in  four  the  hemorrhage 
began  before  the  separation  of  the  cord,  in  three  immediately  after,  and 
in  the  others  at  periods  varying  from  one  to  thirteen  days.  Grandidier, 
quoted  by  Marduel,*  states  that  in  one  case  it  did  not  begin  until  the 
fifty-third.  In  a  large  proportion  of  cases  jaundice  was  present ;  in 
some  the  hemorrhage  was  evidently  dependent  upon  a  hemorrhagic 
diathesis.  The  prognosis  is  quite  unfavorable,  for  a  great  majority  die 
in  a  time  varying  from  a  few  hours  to  some  weeks.  In  the  treatment 

1  American  Journal  of  the  Medical  Sciences,  1852. 

2  Nouveau  Dictionnaire  de  Medecine  et  de  Chirurgie  Pratiques,  vol.  xxiv. 

23 


354  PHYSIOLOGY  OF  THE  PUERPERAL  CONDITION. 

it  is  useless  to  trust  to  astringents  and  compression.  The  only  plan 
which  holds  out  hope  of  success  is  to  pass  a  harelip  pin  or  a  needle 
through  the  skin  of  the  umbilicus  upon  one  side,  then  beneath  the 
bleeding  surface,  and  have  its  point  emerge  from  the  skin  on  the  oppo- 
site side,  and  a  second  pin  is  passed  beneath  and  transverse  to  the  first ; 
a  figure-of-8  ligature  is  made  around  the  projecting  parts  of  each  pin, 
and  the  entire  mass  ligated.  The  pins  are  removed  on  the  fifth  day, 
but  the  ligatures  are  undisturbed  and  left  to  fall  off  with  the  ligated 
mass. 

SECRETION  OF  MILK.  The  enlargement  of  the  breasts  in  male  as 
well  as  in  female  children,  which  with  secretion  of  milk  is  sometimes 
observed  a  few  days  after  birth,  has  been  mentioned.  This  irritation 
almost  always  spontaneously  disappears  in  two  days ;  probably  suppu- 
ration does  not  occur  except  in  those  cases  in  which  the  organ  has  been 
accidentally  bruised,  or  if  injudicious  nurses  have  rudely  squeezed  it  in 
efforts  to  force  the  fluid  out. 

CHANGES  IN  THE  SHAPE  OF  THE  HEAD — CAPUT  SUCCEDANEUM — 
CEPHALH^MATOMA.  The  alterations  in  the  form  of  the  cranium 
occurring  in  childbirth  disappear  in  the  course  of  a  week,  or  a  some- 
what longer  time,  and  Nature  is  quite  able  to  restore  the  original  form 
without  efforts  on  the  part  of  the  physician  or  the  nurse  to  mould  the 
head.  The  caput  succedaneum,  unless  very  large,  usually  disappears 
in  a  few  days,  and  meantime,  if  anything  is  done,  it  may  be  occasion- 
ally bathed  with  a  solution  of  muriate  of  ammonium.  It  is  only 
rarely  that  suppuration  occurs,  and  then  if  the  collection  of  pus  be 
large  it  must  be  opened.  In  cephalhsematoma  absorption  may  occur  in 
from  ten  to  sixty  days  ;  suppuration  is  an  occasional  consequence,  and 
recovery  may  follow  the  discharge  of  the  matter ;  but  sometimes  ne- 
crosis of  the  bone  and  even  perforation,  with  resulting  hernia  of  the 
brain,  are  observed.  Bouchut  suggests  in  case  of  a  large  tumor  which 
does  not  diminish  in  ten  or  twelve  days  under  the  application  of  a 
solution  of  muriate  of  ammonium,  or  of  camphor,  or  of  an  alcoholic 
mixture,  the  evacuation  of  its  contents  by  an  aspirator. 

Winckel  from  the  sixth  to  the  eighth  day  incises  the  tumor,  unless 
it  is  quite  small,  following  the  incision  by  pressure  on  the  detached 
periosteum  with  salicylated  cotton ;  cure  occurs  in  a  few  days.  If  an 
abscess  forms,  it  is  opened,  the  cavity  washed  out  with  one-half  per 
cent,  creolin  mixture,  and  gentle  compression  with  salicylated  cotton, 
previously  advised,  employed. 

CHANGES  IN  THE  SKIN  OF  THE  NEWBORN — DESQUAMATION — 
JAUNDICE.  About  the  third  day  after  birth  desquamation  of  the  epi- 
dermis begins,  and  usually  ends  within  a  week. 

About  two-thirds  of  children  have  what  has  been  called  physiologi- 
cal jaundice,  first  appearing  two  to  four  days  after  birth,  and  continu- 
ing for  a  week  or  ten  days.  This  is  more  marked  in  feeble  infants,  in 
those  born  prematurely  or  who  have  been  exposed  to  cold,  as  is  the 
fact  frequently  in  foundlings.  Various  explanations  have  been  given 
of  the  affection,  but  none  is  .satisfactory.  Active  treatment  is  not  indi- 
cated, as  spontaneous  recovery  occurs. 

The  grave  form  of  jaundice,  or  pathological  jaundice,  often  septic  in 


MANAGEMENT  OF  THE  PUERPERAL  STATE.  355 

its  origin,  is  generally,  if  not  always,  fatal.     It  is  also  more  frequently 
observed  in  children  born  with  pelvic  presentation. 

According  to  Hofmcier,1  every  infant  lives  for  a  time  upon  its  own  organism 
on  account  of  insufficient  nourishment  being  provided  immediately  after  birth ; 
this  is  accompanied  with  degeneration  or  decomposition  of  albumin  and  red 
corpuscles.  Bile-pigment  is  formed  from  the  pigment  of  the  latter.  At  the 
same  time  the  activity  of  the  intestinal  canal  causes  a  great  increase  in  the 
amount  of  bile  secreted,  so  that  the  quantity  is  larger  than  that  excreted  after 
a  certain  degree  of  intensity  has  been  reached,  and  icterus  neonatoruiu  results, 
or,  if  the  skin  be  not  colored,  bile  may  be  found  in  the  urine. 

Bouchut2  regards  hepatitis,  of  which  one  of  the  manifestations  is  jaundice,  as 
very  common  in  the  newborn,  its  causes  being  compression  of  the  body,  or  con- 
tusion of  the  liver  in  labor,  the  impression  of  air  upon  the  external  surface,  and 
umbilical  phlebitis  caused  by  ligating  the  cord,  and  extending  to  the  hepatic 
veins.  In  eight  or  ten  days  the  jaundice  disappears. 

Winckel  adopts  Birch-Hirschfeld's  opinion  that  in  consequence  of  swelling  of 
Glisson's  capsule,  resulting  from  lessened  pressure  in  the  portal  system  following 
division  of  the  cord,  the  bile-ducts  are  compressed,  and  therefore  the  jaundice. 

But  in  the  malignant  form  of  jaundice  there  are  fever,  swelling  of  the  abdo- 
men, and  tenderness  in  the  right  hypochondrium  with  enlargement  of  the  liver  ; 
there  may  be  nausea  and  vomiting,  and  in  some  cases  epistaxis,  purpura,  or 
haematemesis.  The  respiration  is  difficult,  hiccough  frequent,  and  as  M.  Richard 
points  out,  when  this  state  is  prolonged  or  increases,  a  profound  change  of  ex- 
pression follows,  the  eyes  are  fixed,  convulsions  affecting  the  muscles  of  the  face 
and  of  the  limbs  occur,  the  infant  sinks  into  collapse,  becomes  cold  and  dies. 

BATHING — SLEEPING — NOURISHMENT.  An  infant  should  have  a 
bath  once  in  twenty-four  hours,  in  order  to  insure  that  perfect  cleanli- 
ness upon  which  its  health  and  comfort  so  greatly  depend.  It  should 
not  be  accustomed  to  sleep  in  the  nurse's  arms,  nor  in  the  mother's 
bed,  but  in  a  separate  one.  As  previously  stated,  it  ought  to  be  ap- 
plied to  the  mother's  breast  twelve  hours  after  birth.  It  ought,  as  as- 
serted by  Kleinwiichter,  to  be  subjected  to  a  definite  order  in  sucking 
from  the  beginning.  After  the  secretion  of  milk  has  become  abundant, 
generally  the  third  day,  "  the  child  may  be  put  to  the  breast  every  two 
hours,  for  at  that  time  the  capacity  of  the  stomach  is  not  great ;  after 
four  or  five  days  once  in  three  hours,  and  at  night  there  should  be  an 
interval  of  six  or  seven  hours ;  later  on  six  applications  in  twenty-four 
hours  will  suffice." 

The  child,  as  a  rule,  loses  weight  during  the  first  few  days ;  the  loss 
is  from  150  to  200  grammes,  and  is  to  be  attributed  to  discharge  of 
urine  and  of  meconinm,  and  also  to  the  scanty  supply  of  nourishment ; 
at  the  end  of  the  first  week  the  child  weighs  nearly  or  quite  as  much 
as  it  did  at  birth. 

The  best  proof  of  the  good  quality  and  of  the  sufficient  quantity  of 
the  milk,  whether  of  wet-nurse  or  of  mother,  is  given  by  the  thriving 
of  the  infant.  If  the  child  grows  well,  is  plump  and  healthy,  it  must 
have  good  and  abundant  food ;  the  old  law,  "  by  their  fruits  ye  shall 
know  them,"  is  here  quite  applicable.  Nevertheless,  other  means  may 
be  mentioned.  When  the  infant  is  at  the  breast  it  can  be  known  that 
it  is  getting  milk  readily  by  the  movements  of  the  cheeks  alternating 
with  those  of  swallowing ;  the  last  is  often  accompanied  by  a  sound 

1  Kormann.        ..  2  Op.  cit. 


356  PHYSIOLOGY  OF  THE  PUERPERAL  CONDITION. 

which  Hubert  compares  to  that  made  in  uttering  the  French  word 
glou-glou.  So,  too,  if  the  milk  is  abundant  it  is  found  in  drops1  at  the 
angles  of  the  mouth  or  upon  the  adjacent  part  of  the  cheek,  after  the 
child  has  finished  nursing. 

It  sometimes  happens  that  the  mother  has  apparently  a  sufficient  supply  of 
milk,  but  its  inferior  quality  is  shown  not  only  by  the  child's  failing  to  thrive, 
but  by  disorders  of  digestion,  attacks  of  colic,  and  the  abnormal  character  of  the 
stools.  It  may  be  that  one,  two,  or  three  meals  of  artificial  food  each  twenty- 
four  hours  will  work  a  happy  change  in  the  infant's  condition,  and  the  mother, 
less  worried  and  her  rest  less  disturbed,  and  at  the  same  time  less  frequently 
nursing  the  infant,  secretes  a  better  milk,  and  therefore  she  may  continue  to 
nurse,  her  deficient  supply  being  thus  supplemented. 

Weighing  the  child  from  time  to  time  is  an  excellent  test  of  the  quantity  and 
quality  of  milk :  the  increase  in  weight  ought  to  be  about  one  ounce  a  day. 

SELECTION  OF  A  WET-NURSE.  The  most  desirable  age  for  a  wet- 
nurse  is  from  twenty-two  to  thirty-five  years.  If  a  married  woman,  it 
is  better  that  she  should  be  a  multipara,  for  the  milk  is  then  not  only 
more  abundant,  but  she  is  less  liable  to  suffer  from  disease  of  the  nipple, 
or  mammary  inflammation,  and,  moreover,  has  acquired  useful  experi- 
ence in  the  care  of  an  infant.  If  unmarried,  she  ought  to  be  a  primi- 
para,  for,  as  suggested  by  Hubert,2  while  the  first  fault  might  be 
excused,  after  the  commission  of  a  second  there  would  be  no  guarantee 
that  a  third  might  not  occur  while  she  was  nursing. 

Delore  states  that  from  the  time  of  Ambrose  Pare  blonde  women  were  consid- 
ered inferior  nurses,  and  indicates  that  brunettes  are  generally  preferred  as 
habitually  more  vigorous.  Dionis  asserted  that  the  best  nurses  were  those  of  a 
sanguine  temperament,  and  who  have  black  or  brown  chestnut  hair.  Bad  nurses 
were  those  of  a  bilious  or  melancholic  temperament,  and  who  have  blonde  or 
red  hair. 

She  must  be  free  from  syphilis,  tuberculosis,  or  exanthematous  dis- 
ease. There  ought  not  to  be  a  difference  of  more  than  two  months 
between  the  birth  of  her  own  and  that  of  the  infant  she  nurses.  The 
breasts  should  be  of  medium  size,  and  the  nipple  free  from  excoria- 
tions, of  such  size  that  the  infant  can  readily  grasp  it  with  its  mouth, 
and  the  milk  be  easily  drawn.  As  a  rule,  a  woman  who  menstruates 
regularly  ought  not  to  be  taken  as  a  wet-nurse.  Supposing  everything 
favorable  as  to  the  supply  of  milk  and  the  physical  health,  considera- 
tion should  be  given  to  her  moral  character  and  disposition,  for  while 
it  is  true  that  the  milk  of  the  nurse3  can  transmit  no  intellectual  or 

1  The  most  gifted  poetess  of  the  century,  if  not  of  all  centuries,  Elizabeth  Barrett  Browning,  has 
alluded  to  this  where  she  speaks  of  the  babe  "  knowing  all  things  by  their  blooms,  not  their 
roots,"  etc. : 

"And  human  love,  by  drops  of  sweet 
White  nourishment  still  hanging  round 
The  little  mouth  so  slumber-bound." 

!  The  remark  of  Hubert  suggests  quoting  the  following  observation  by  Goldsmith  : 
' '  For  the  first  time  the  very  best  may  err ;  art  may  persuade,  and  novelty  spread  out  its  charm. 
The  first  fault  is  the  child  of  simplicity,  but  every  other,  the  offspringof  guilt."—  Vicar  of  Wakefiled. 
The  belief  that  the  milk  which  nourished  the  newborn  had  much  to  do  with  the  formation  of 
the  character  is  an  old  one ;  even  to  this  day  it  is  not  uncommon  to  hear  one  speak  of  having 
sucked  in  with  his  mother's  milk  certain  beliefs  or  principles,  especially  those  of  a  religious  char- 
acter ;  but  the  expression  is  used  more  as  a  figure  of  speech  to  indicate  how  completely  and  thor- 
oughly those  beliefs  or  principles  are  interwoven  with  his  spiritual  nature,  having  been  taught 
him  in  the  very  dawn  of  his  intelligent  existence,  than  that  they  came  by  the  nourishment  de- 
rived from  the  mother.    The  famous  Cato,  however,  did  believe  that  affection  might  be  thus  com- 


MANAGEMENT  OF  THE  PUERPERAL  STATE.  357 

moral  qualities  to  the  nursling,  yet  it  is  also  true  that  with  the  devel- 
opment of  the  infant's  intelligence  it  will  receive  in  its  plastic  nature 
impressions  more  or  less  profound  and  permanent  from  one  with  whom 
it  is  so  intimately  and  constantly  associated  as  the  nurse.  Moreover, 
the  question  as  to  her  disposition  is  an  important  one,  siuce  for  the  time 
being  she  is  to  some  degree  a  member  of  the  family  ;  taking  the  child 
to  her  own  home  to  nurse  is  quite  exceptional.1  Further,  it  is  generally 
admitted  that  the  milk  may  at  once  undergo  important  modifications  in 
consequence  of  profound  mental  emotion.  Devilliers  remarks  that  it 
would  be  easy  to  adduce  examples  of  nurses  in  whom  violent  passions, 
especially  anger,  changed  the  qualities  of  the  milk  so  as  to  disturb  the 
health  of  the  infant,  and  even  cause  severe  convulsions.  And  he  adds  : 
"A  thousand  times  better  a  woman  somewhat  stupid,  of  an  impassive 
character  and  almost  insensible  to  passions,  than  a  nurse  with  intelli- 
gence more  developed,  but  of  a  passionate  and  choleric  character." 

ARTIFICIAL  FEEDING.  In  case  the  mother  cannot  nurse  her  infant, 
and  it  is  impossible  to  obtain  a  suitable  wet-nurse,  artificial  nourish- 
ment must  be  used.  Condensed  milk  is  a  very  convenient  form  of  food, 
especially  in  cities  and  in  hot  weather,  when  it  may  be  difficult  to  obtain 
pure  milk  from  the  cow.  Babies  like  it,  and  rapidly  fatten  taking  it, 
and  they  are  free  from  constipation.  The  liability  to  rhachitis  in  chil- 
dren living  on  it  exclusively  has  been  stated  by  Fleischmaun,  Lusk, 
Galabin,  and  Starr.  Runge  remarks  :  "  The  condensed  Swiss  milk 
contains  39  to  48  per  cent,  of  sugar,  and  therefore  is  not  to  be  employed 
exclusively."  The  milk  of  the  cow  is  that  which,  as  a  rule,  can  be 
best  used  for  the  nourishment  of  the  infant ;  it  has  been  the  practice  to 
select  the  milk  from  one  cow ;  Winckel,  however,  advises  that  of  sev- 
eral mixed  together.  In  order  to  remove  all  possible  infectious  matter 
the  milk  ought  to  be  boiled  before  using  it;  recently  there  have  been 
invented  apparatuses  for  sterilizing  milk ;  milk  after  being  subjected  to 
this  process  may  be  kept  for  several  days  without  change  ;  the  great 
lessening  of  infant  mortality  in  hospitals  since  the  introduction  of  ster- 
ilized milk  is  conclusive  proof  of  its  value. 

Cow's  milk,  after  sterilization,  will  be  diluted  with  two  parts  of  water 
that  has  been  boiled,  and  sweetened  with  milk  sugar,  for  the  infant  during 
the  first  four  weeks.  Then  the  proportion  of  water  is  gradually  less- 
ened until  at  the  end  of  eight  weeks  equal  quantities  of  water  and  milk 
are  given.  At  four  mouths  the  milk  is  given  undiluted. 

But  cow's  milk,  even  with  these  additions,  differs  from  human  milk, 
and  various  methods  have  beei\  employed  to  make  an  artificial  fluid  of 
which  the  former  is  the  base,  which  shall  be  more  nearly  like  that  which 
mothers  provide  for  the  infant.  The  following  is  a  formula  approved 
by  Dr.  Fullerton : 

municated,  for,  according  to  Plutarch's  statement,  he  had  his  wife,  whenever  she  nursed  her  son, 
also  give  her  breast  to  the  infants  of  her  slaves,  so  that  sucking  the  same  milk  they  might  have  an 
affection  for  him.  Cruelty  of  disposition  was  also  thought  to  be  derived  from  the  first  nourish- 
ment. Thus  among  all  the  bitter  reproaches  which  the  deserted  Dido  cast  upon  the  escaping 
2Eneas,  one  of  the  severest,  as  indicating  his  cruel  nature,  was  that  he  had  nursed  the  breasts  of 
Hyrcanian  tigresses.  Gardien  quotes  the  statement  that  if  young  lions  are  nourished  by  cow's 
milk  they  are  gentle,  and,  on  the  other  hand,  that  if  puppies  are  brought  up  by  wolves  they  are 
fierce. 

1  This  seems  not  to  have  been  extraordinary  among  the  Egyptians,  as  the  story  of  Moses'  in- 
fancy suggests. 


358  PHYSIOLOGY  OF  THE  PUERPERAL  CONDITION. 

Milk fgij. 

Cream f  |iij. 

AVater f.5x. 

Milk-sugar 3vj:|. 

"  Put  iu  a  flask  in  the  steamer  and  steam  for  twenty  minutes ;  then 
remove  the  flask  from  the  steamer,  and  when  still  slightly  warm  add 
lime-water  f  5j.  It  may  be  placed  on  ice,  and  a  sufficient  quantity  taken 
from  it  when  needed." 

DIFFICULTY  AND  PAIN  IN  URINATING.  It  occasionally  happens 
that  male  children  have  great  pain  before,  and  some  difficulty  in  urina- 
tion; upon  examiuation  it  will  be  found  that  the  trouble  arises  from 
stenosis  of  the  orifice  in  the  prepuce.  Of  course,  circumcision  is  a  cer- 
tain and  permanent  cure,  but  dilatation  will  also  be  successful,  and  it 
will  generally  be  preferred ;  dilating  may  be  done  by  drawing  the  pre- 
puce over  the  closed  blades  of  a  suitable  forceps  inserted  in  its  orifice, 
and  then  opening  the  blades  until  about  one-half  of  the  glans  is  ex- 
posed; cold  water  is  applied  for  an  hour,  and  the  dilatation  may,  if 
necessary,  be  repeated  after  one  or  more  days. 

THRUSH/  SPRUE,  MUGUET.  These  different  names  are  applied  to 
an  affection  of  the  mouth  of  the  infant  characterized  by  the  appearance 
upon  the  tongue  and  upon  the  inner  surface  of  the  cheeks,  thence  pos- 
sibly extending  to  other  or  to  all  parts  of  the  buccal  mucous  membrane, 
of  small,  white  curd-like  patches.  The  affection  is  much  more  frequent 
in  the  hand-fed  than  in  the  breast-fed,  and  is  not  so  much  a  disease  as 
indicative  of  a  diseased  condition  of  the  mucous  membrane  and  of  the 
secretions,  furnishing  a  suitable  soil  for  the  growth  of  the  fungus,  sac- 
charomyces  albicans,  formerly  called  by  Robin  o'idium  albicaus.  The 
occurrence  of  such  a  growth  is  usually  an  indication  that  proper  care  of 
the  child's  mouth  has  not  been  taken  in  regard  to  washing  it,  or  that  in 
artificial  feeding  either  the  food  is  not  in  suitable  condition,  or  the  vessel, 
the  tube,  and  the  nipple  are  not  thoroughly  cleansed.  The  best  local 
application  is  borax ;  it  may  be  used  as  a  solution  in  water,  twenty 
grains  to  the  ounce,  freely  pencilled  three  or  four  times  a  day  upon  the 
patches,  or,  as  advised  by  Winckel,  a  mixture  iu  syrup  may  be  used,  of 
which  half  a  teaspoonful  is  given  one  to  three  times  a  day,  the  child  by 
the  movements  of  its  tongue  making  a  better  application  of  the  remedy 
to  the  diseased  places  than  can  be  done  with  a  brush. 

1  Thrush,  probably  from  the  same  root  as  thrust  and  sprue,  spelled  by  some  lexicographers 
sprew,  from  the  same  root  as  sprout. 


SECTION  I. 


INTRODUCTORY.     The  pathology  of  pregnancy  includes  : 

First.  The  abnormal  position  occupied  by  the  ovum  completely  or 
partially.  Thus,  if  the  ovum  be  outside  the  uterine  cavity,  it  is  out  of 
place,  a  condition  commonly  known  as  extra-uterine  gestation,  but  which 
has  been  more  appropriately  called  by  Barnes  ectopic. 

Further,  the  placenta,  instead  of  having  its  site  in  the  upper  portion 
of  the  uterus,  may  in  whole  or  in  part  be  in  the  lower  uterine  segment, 
that  is,  be  prsevial. 

These  are  the  gravest  deviations  from  normal  pregnancy. 

Following  the  consideration  of  placenta  prsevia,  of  which  the  domi- 
nant symptom  is  hemorrhage,  that  has  been  called  unavoidable,  there 
will  be  presented  the  subject  of  accidental  hemorrhage,  or  bleeding  from 
premature  detachment  of  the  placenta  occupying  its  normal  site. 

Second.  The  woman  may  suffer  from  exaggeration  of  a  physiological 
change  incident  to  gestation,  or  disease  of  an  organ  may  otherwise  be 
consequent  upon  the  pregnant  condition ;  if  she  were  not  pregnant, 
neither  morbid  manifestation  would  occur.  In  illustration,  the  common 
nausea  and  vomiting  of  pregnancy  may  be  so  aggravated  that  peril  to 
life  is  imminent.  Again,  albumiuuria  may  be  caused  by  gestation. 

Third.  The  woman  when  she  becomes  pregnant  may  be  laboring 
under  some  chronic  disease,  as  pulmonary  tuberculosis,  or  syphilis. 

Fourth.  Gestation  does  not  exempt  her  from  acute  diseases;  these, 
then  occurring,  as  erysipelas,  variola,  scarlatina,  cholera,  pneumonia,  etc., 
may  be  injuriously  affected  by  the  pregnancy,  or  on  the  other  hand  have 
a  deleterious  influence  upon  the. latter. 

Fifth.  Diseases  of  the  sexual  organs  are  necessarily  included  in  the 
pathology  of  pregnancy. 

Sixth.  Surgical  operations,  or  iujuriesand  accidents  occurring  in  preg- 
nancy, are  to  be  considered. 

Seventh.  Diseases  of  the  ovum  make  an  important  part  of  the  path- 
ology of  pregnancy. 

Eighth.  As  a  result  usually  of  causes  included  in  some  of  these  classes, 
the  pregnancy  may  be  arrested,  and  therefore  such  interruption,  whether 
by  abortion  or  by  premature  labor,  must  be  here  presented. 


CHAPTEK  I. 

ECTOPIC  DEVELOPMENT  OF  THE  OVUM  OR  OF  THE  PLACENTA. 

ECTOPIC  PREGNANCY — DEFINITION  AND  ETIOLOGY.  The  normal 
place  in  which  the  ovum  is  developed  is  the  uterine  cavity,  and  there- 
fore if  this  development  occurs  in  the  tube,  in  the  ovary,  etc.,  the 
ovum  is  ectopic,  that  is,  out  of  place,  and  the  pregnancy  is  so  called. 
While  the  causes,  as  Martin  has  said,1  are  obscure,  this  is  true  in  general, 
for  there  are  instances  in  which  the  etiology  is  certain,  though  in  many 
others  we  must  be  coutent  for  the  present  with  probable  explanations. 

1.  The  body  of  the  uterus  having  been  removed,  impregnation  may 
occur.     This  happened  in  a  patient  of  Koeberle,  the  uterus  having  been 
amputated  because  of  a  myoma ;  there  was  a  fistula  in  the  cervical  cica- 
trix,  and  through  this  spermatozoids  entered.     Kaltenbach  suggested 
that  a  similar  event  might  happen  in  case  of  removal  of  the  inverted 
uterus,2  or  after  a  Porro  operation. 

2.  The  ovum  may  escape  into  the  abdominal  cavity,  from  the  uterus, 
through  an  opening  in  the  latter  which  remained  after  a  Csesarean  sec- 
tion ;  this  occurred  in  a  case  reported  by  Lecluyse. 

3.  Absence  of  ciliated  epithelium  from  the  tube.     This  absence  is  ex- 
plained as  the  result  of  catarrhal  inflammation.    Those  who  hold  that  im- 
pregnation normally  occurs  in  the  uterine  cavity  claim  that  these  cilia  by 
their  movements  toward  the  uterus  prevent  the  spermatozoids  from 
ascending  the  tube,  but  if  they  have  been  destroyed  no  obstacle  is 
offered.     On  the  other  hand,  admitting  impregnation  in  the  external 
portion  of  the  tube,  the  belief  generally  held,  ciliated  action  is  necessary 
for  the  transfer  of  the  ovum  to  the  uterus.     The  result  is  the  sam,e, 
whichever  theory  is  adopted. 

4.  Narrowing  of  the  tube.     The  lessened  diameter  of  a  part  of  the 
oviduct  may  be   the   result  of  perimetritic  adhesions,  of  twisting,  of 
cicatricial   contraction  following   inflammation,  of  a  polypus,  or  of  a 
fibroid  tumor  of  the  uterus  in  the  vicinity  of  the  uterine  entrance  of 
the  duct. 

5.  Impermeability  of  the  oviduct.     An  ectopic  gestation  thus  caused 
must  be  explained  by  the  hypothesis  of  an  external  migration  of  the 
spermatozoids  or  of  the  ovule  after  its  impregnation.  Thus,  supposing  an 
atresia  at  some  part  of  one  tube,  the  other  being  normal,  the  spermato- 
zoids passing  through  the  latter,  the  ovule  liberated  from  the  »ovary  of 
the  opposite  side  is  impregnated,  and  entering  the  other  tube  is  arrested 
by  the  obstruction.     Or,  an  impregnated  ovule  may,  it  is  supposed,  pass 
over  to  the  opposite  tube.     But  these  explanations  are  chiefly  hypo- 

1  Congrfcs  PSriodique  International  de. Gynecologic  et  d'Obstetrique.    Bruxelles,  1894. 

*  MUller  reported  a  case  of  ectopic  gestation  in  a  hernial  sac ;  A.  Martin- Wend ler,  in  the  am- 
pulla of  a  tube  that  after  the  extirpation  of  a  cancerous  uterus  had  been  pushed  into  the  vagina, 
and  J.  Veil  a  similar  case.—  Ahlfeld. 


ECTOPIG  PREGNANCY.  361 

thetical,  and  there  must  in  some  cases  be  a  doubt  as  to  whether  the  closure 
of  the  tube  preceded  or  followed  the  impregnation.  The  last  observation 
also  may  sometimes  apply  to  those  cases  in  which  iutra-uteriue  migration 
of  the  ovum  has  been  observed.  In  this  migration  the  ovum  entering 
through  the  pervious  tube  is  found  developed  in  the  partially  closed  tube 
of  the  opposite  side. 

6.  Accessory  tubes  and  tubal  ostia  may  be  causes  of  ectopic  gestation, 
as  recently l  maintained  by  Siinger. 

Dr.  Joseph  Price,  of  this  city,  has  had  108  cases  of  ectopic  gestation, 
and  all  of  them,  he  states  in  a  recent  communication  to  me,  were  pri- 
marily tubal  with  one  exception,  possibly  two,  the  ovary  involved  form- 
ing part  of  the  sac. 

He  regards  the  following  as  causes :  "  Catarrhal  troubles  and  dis- 
torted positions  of  the  pelvic  viscera  ;  emotional  disturbance  is  no  small 
factor." 

The  abnormal  situation  of  the  ovum  has  occurred  in  many  cases  after 
a  period  of  sterility,  or  after  an  attack  of  gonorrhoea,  or  after  a  child- 
birth followed  by  pelvic  inflammation.  The  great  majority  of  cases 
are  observed  in  women  who  have  previously  borne  one  or  more  children. 
Several  cases  are  recorded  of  ectopic  associated  with  normal  pregnancy, 
and  a  few  of  double  ectopic  gestation.2  It  is  quite  possible  that  some  of 
the  cases  reported  as  double  ectopic  gestation  were  really  single,  for 
hsematosalpinx  is  not  infrequent,  affecting  the  tube  not  occupied  by  the 
ovum. 

FREQUENCY.  It  is  impossible  even  to  approximate  an  accurate  state- 
ment as  to  how  often  ectopic  gestation  occurs  in  comparison  with  normal 
pregnancies.  The  statements  of  authorities  widely  vary.  Thus  Wiuckel 
saw  ectopic  gestation  in  16  cases  to  about  222,000  births,  while  Bandl 
had  only  3  in  60,000  births ;  Ahlfeld  speaks  of  only  one  case  observed 
by  him  in  twelve  years  at  Giessen  and  Marburg,  and,  on  the  other  hand, 
Dr.  Price  has  met  with  so  large  a  number  of  cases,  as  stated  above, 
that  he  regards  the  accident  as  occurring  once  in  1000  pregnancies. 

In  arriving  at  a  probable  conclusion  as  to  the  frequency  of  ectopic 
pregnancy,  it  must  be  remembered  that  the  late  Matthews  Duncan,  justly 
as  I  believe,  said,  "  There3  are  many  cases  in  which  the  disease  is  never 
suspected  ;  the  foetus  dies,  and  is,  so  to  speak,  entombed."  Kaltenbach 
speaks  of  hemorrhage  into  the  tube  which,  in  part  with  the  ovum,  finds 
its  way  into  the  abdomen,  where  the  embryo  is  quickly  absorbed,  while 
the  amnion  itself  and  especially  the  chorial  villi  with  their  characteristic 
epithelium  remain  a  longer  time  between  the  blood-clots.  So,  too,  in 
some  of  the  cases  of  tubal  abortion  in  the  first  weeks,  the  developing 
ovum  occupying  a  place  near  the  pavilion,  and  expelled  into  the  abdomi- 
nal cavity  by  the  contractions  of  the  oviduct,  it  is  quite  probable  the 

1  Monatschrift  f.  Geburtshiilfe  und  Gynakologie,  January,  1895.    It  is  of  interest  to  observe  in 
this  connection  that  Kossmann  states,  Zeitschrift  filr  Geburtshiilfe  und  Gynakologie,  1894,  that 
accessory  tubes  and  tubal  ostia  are  found  in  4  to  10  per  cent,  of  women. 

2  One  of  the  most  remarkable  explanations  of  an  ectopic  gestation  is  given  in  the  Philadelphia 
Medical  Museum,  vol.  i.,  new  series,  1811.    Dr.  W.  B.  Smith,  of  Jamestown,  Va.,  describes  the 
autopsy  of  a  colored  woman,  in  which  he  found  double  ovarian  pregnancy,  one  ovary  containing 
a  ftetus  four  inches,  and  the  other  one  eight  inches  long.    The  tubes  were  diseased,  so  that  the 
"  male  semen  "  could  not  have  passed  through  either,  and  hence  he  suggests  that  impregnation 
resulted  from  the  semen  being  taken  up  by  the  blood,  and  thus  carried  to  the  ovaries. 

3  London  Lancet,  July  13, 1889.  The  statement  by  Duncan,  quoted  above,  is  confirmed  by  Ahlfeld. 
If  the  fostus  "  dies  early,  the  sac  may  atrophy  without  the  woman  having  any  observable  injury." 


362 


THE  PATHOLOGY  OF  PREGNANCY. 


expulsion  may  take  place  without  any  serious  symptoms,  and  the  patient 
soon  recover. 

I  therefore  repeat  the  statement  made  in  the  second  edition  of  this 
work,  that  probably  there  is  one  case  of  ectopic  gestation  to  500  of 
normal  pregnancy.  Those  who  make  their  estimates  from  abdominal 
sections  and  from  post-mortem  examinations  probably  omit  of  the  entire 
number  of  ectopic  pregnancies  quite  as  many  as  they  record. 

VARIETIES.  These  are  primary  and  secondary,  and  of  each  there  are 
two.  Primary  ectopic  gestation  is  either  tubal  or  ovarian,  with  the  sub- 
varieties  tubo-uterine,  also  called  interstitial,  tubo  abdominal,  and  tubo- 
ovarian.  The  secondary  varieties  are  abdominal  and  subperitoneo- 
pelvic,  or  pregnancy  in  which  the  developing  ovum  is  between  the  layers 
of  one  of  the  broad  ligaments,  the  result  of  a  ruptured  tubal  pregnancy. 


PREGNANCY  IN  THE  EXTERNAL  THIRD  OF  THE  LEFT  TUBE.    (After  WINCKEL.) 
a.  Ovary,    b.  Left  tube.    c.  Tubal  gestation  cyst.    d.  Adhesion. 

TUBAL  PREGNANCY.  This  is  by  far  the  most  frequent  variety  of 
ectopic  gestation.  Some  indeed  contend  that  it  is  the  only  one,  Dr. 
Doran,  for  example,  stating  that  he  is  inclined  to  believe  that  all  are 
tubal. 

One  of  three  events  occurs :  Tubal  abortion,  rupture  of  the  tube,  or 
completion  of  pregnancy ;  the  second  is  the  most  frequent,1  rupture 
generally  taking  place  within  six  to  eight  weeks,  and  the  last  is  the 
rarest.  That  the  development  of  the  ovum  may  continue  until  term  is 
proved  by  a  few  cases,  among  them  one  of  Spiegel  berg's,  and  in  publish- 
ing it  he  added  five  similar  cases  reported  by  others,  and  one  reported 
by  Dr.  Joseph  Eastman,  of  Indianapolis,  in  which  he  operated  at  terra, 
saving  both  mother  and  child.  Kaltenbach  admits  it,  stating,  however, 
that  it  is  exceedingly  rare. 

DEVELOPMENT  OF  THE  OVUM  IN  TUBAL  GESTATION.  The  ovum2 
has  the  same  deciduous  membranes  formed  from  the  mucous  membrane 

1  Abortion  is  about  as  frequent  as  tubal  rupture,  according  to  some  observers.    Ortbman,  indeed, 
Zeitschrift  f.  Geburtshlilfe  und  Gynakologie,  1894,  of  124  cases  of  tubal  pregnancy  in  the  first  four 
months,  found  61  each  of  abortion  and  of  rupture  ;  in  2  each  accident  occurred. 

2  Lederer :  Beitrage  znr  Anatomic  der  Tuberschwangerschaft.    Berlin,  1888,  and  Berlin  Thesis, 
by  John  von  Glahn,  1888. 


ECTOPIC  PREGNANCY. 

FIG.  155. 


363 


TUBAL  PREGNANCY.    RUPTURE  OF  GESTATION  CYST.    (From  RAMSBOTHAM.) 

of  the  tube  that  in  normal  pregnancy  are  contributed  by  the  lining  mem- 
brane of  the  uterus.  The  muscular  fibrillse  of  the  tubes  during  the 
first  two  mouths  hypertrophy,  and  then  a  retrogressive  metamorphosis 
begins,  caused  by  a  pressure-atrophy  from  the  growing  ovum.  The 


ACTUAL  VIEW  OF  PLACENTAL  VILLA.  (Drawn  by  E.  TEICHELMAN  from  section  made  by  BERRY  HART.) 

c.  Encroaching  upon  and  causing  thinning  of  the  muscular  wall  (a)  of  the  Fallopian  tube. 

b.  Maternal  blood  sinuses. 


364 


THE  PATHOLOGY  OF  PREGNANCY. 


chorial  villi,  forerunners  of  the  foetal  portion  of  the  placenta,  enter  the 
connective  tissue ;  their  penetration  into  the  muscular  layer,  observed  in 
one  case  by  Leopold,  was  not  found  in  the  examination  made  by  Diihrs- 
sen.  The  preceding  illustration,  Fig.  156,  is  from  Tait's  lectures  on 
"  Ectopic  Pregnancy." 

In  Zucker's1  case  of  tubal  pregnancy  rupture  with  fatal  hemorrhage 
occurred  when  the  gestation  was  only  between  two  and  three  weeks. 
The  rupture  is  generally  into  the  peritoneal  cavity,  and  very  rarely  be- 
tween the  layers  of  the  broad  ligament.  In  many  cases  the  mother, 
unless  saved  by  a  surgical  operation,  perishes  within  a  few  hours.  But 
if  the  rupture  should  occur  in  that  portion  of  the  tube  not  covered  by 
peritoneum,  the  danger  is  much  less,  for  the  connective  tissue  uniting 
the  two  folds  of  peritoneum  not  yielding  readily,  in  some  degree  restrains 
the  bleeding,  and  its  meshes  facilitate  coagulation.  In  the  great  majority 
of  cases  the  embryo  dies,  and  a  haematoma  results,  which  remains  for  a 
time;  this  may  be  gradually  absorbed,  or  suppuration  with  the  forma- 
tion of  an  abscess  occurs.2  But  in  exceptional  instances  the  develop- 


FIG.  157. 


FIG.  158. 


DIAGRAMMATIC  SECTION  OF  FALLOPIAN  TUBE  REPRESENTING  THE  Two  DIRECTIONS  OF  RUPTURE. 

1.  INTO  THE  PERITONEAL  CAVITY.  2.  INTO  THE  CAVITY  OF  THE  BROAD  LIGAMENT.  (From  TAIT.) 

a.  Clot  at  point  of  rupture.    6.  Wall  of  the  Fallopian  tube.    c.  Cavity  of  the  broad  ligament, 

with  (3)  folds  separated  by  hsemic  effusion,  o. 

ment  of  the  ovum  continues,  and  there  is  an  extra-peritoneal,  broad 
ligament,  or  intra-ligamentous  pregnancy.  The  usual  course  of  this 
pregnancy  will  be  described  hereafter. 

The  possibility  of  a  development  of  the  ovum  in  the  tube  and  liga- 
ment should  be  borne  in  mind ;  then  there  is  a  tubo-ligamentous  preg- 
nancy. Some  authorities  regard  those  rare  cases  in  which  a  tubal 
pregnancy  has  gone  to  term  as  oftener  instances  of  a  gestation  in 

1  Centralblatt  f.  Gynakol.,  1888. 

a  It  is  incorrect  to  speak  of  intra-peritoneal  and  extra-peritoneal  haematocele.  An  encysted 
collection  of  blood  in  the  peritoneal  cavity  is  a  hsemalocele,  and  a  corresponding  blood  tumor  in 
the  connective  tissue  is  a  hrematoma. 


ECTOPIC  PREGNANCY. 


365 


which  the  ovum  occupies  the  tube  and  the  space  between  the  separated 
layers  of  the  broad  ligament.  It  would  seem  probable  that  as  a  rule, 
in  such  a  variety  originally  of  tubal  pregancy,  no  violent  rupture,  such 


PREGNANCY  OF  THE  RIGHT  TUBE.    PARTIALLY  INTRA-LIGAMENTOUS.    (From  ZWEIFEL.) 
a.  Right  tube.    b.  Ovary,    c.  Gestation  cyst. 

as  is  represented  in  Fig.  158,  occurs,  but  a  gradual  entrance  of  the 
ovum  takes  place. 

FIG.  160. 

./* 


DIAGRAMMATIC  REPRESENTATION  OF  INTERSTITIAL  TUBAL  PREGNANCY  AT  TIME  OF  RUPTURE. 

(From  TAIT.) 

INTERSTITIAL  PREGNANCY.  Mr.  Tait  asserts  that  this  variety  of 
ectopic  gestation  is  uniformly  fatal  by  primary  intra-peritoneal  rupture 
before  the  fifth  month.  The  assertion,  however,  ignores  the  case  of 


366  THE  PATHOLOGY  OF  PREGNANCY. 

Braxton  Hicks,1  which  in  the  sixth  month  of  pregnancy  ended  by  the 
discharge  of  the  foatus  through  the  natural  passage ;  the  placenta  was 
retained,  and  four  days  subsequently  violent  pain  occurred,  and  the 
patient  died  in  two  hours  m  collapse.  The  post-mortem  proved  that 
there  had  been  an  interstitial  pregnancy,  and  that  while  the  fostus  es- 
caped through  a  rupture  into  the  uterus,  a  subsequent  rupture  of  the 
gestation  cyst  into  the  peritoneal  cavity  had  occurred  with  fatal  hemor- 
rhage. It  ignores  the  case  of  Maschka,  in  which  a  double  rupture  of 
an  interstitial  pregnancy  took  place,  the  body  of  the  fetus  being  ex- 
tracted through  the  uterus,  while  the  head  escaped  into  the  abdominal 
cavity.  Spiegelberg  has  asserted  that  in  rare  cases  the  pregnancy  may 
go  to  term,  and  there  have  been  several  cases  reported  in  which  the 


FIG.  161. 


TUBO-UTERINE,  INTERSTITIAL  OR  MURAL  GESTATION. 

a.  Cavity  of  uterus  clothed  with  decidua.    6.  Broad  ligament,    c.  Tubo-uterine  sac  which 
contained  embryo,    d,  d.  Thicker  part  of  cyst- walls,    e.  Placenta. 

ovum  was  entirely  expelled  through  the  natural  passage.  While  con- 
fessing to  skepticism  in  regard  to  many  of  these  reported  cases,  in  some 
denial  of  the  accuracy  of  the  statements  made  by  reputable  and  able  ob- 
servers would  be  unjust.  That  such  an  event  is  frequent  is  in  the  highest 
degree  improbable,  independently  of  the  fact  that  interstitial  is  an  ex- 
ceedingly rare  form  of  ectopic  gestation,  and  that  many  of  the  cases 
should  be  credited  by  the  reporters  and  by  the  profession  only  illus- 
trates the  old  adage  that  opinion  travels  the  world  without  a  passport. 

Interstitial  pregnancies  are  more  frequent  in  medical  journals  than  they  are 
in  autopsies  or  in  abdominal  sections.     Careful  and  impartial  study1  of  reports 

1  London  Obstetrical  Society's  Transactions,  vol.  ix. 


ECTOPIC  PREGNANCY. 


367 


of  some  of  the  unverified  cases  of  interstitial  pregnancy  will  convince  any  one 
that  they  were  in  all  probability  normal  pregnancies,  and  meddlesome  treat- 
ment caused  abortion.  It  should  be  remembered  that  some  of  the  best  authori- 
ties regard  the  diagnosis  of  interstitial  pregnancy  impossible.  A  few  years  since 
a  former  pupil  and  medical  friend  in  a  distant  city  wrote  me  of  a  double  inter- 
stitial pregnancy  occurring  in  one  of  his  patients ;  she  was  being  treated  by  a 
gynecologist  for  subinvolution  of  the  womb,  the  sound  having  been  more  than 
once  introduced,  and  applications  to  the  endometrium  made.  Miscarriage  of 
one  embryo  occurred,  and  within  a  few  days,  of  the  second.  Both  of  the  medi- 
cal gentlemen  who  examined  the  patient  prior  to  the  abortions  were  confident 
that  the  uterine  cavity  was  empty,  and  they  alike  believed,  after  these  occurred, 
that  there  had  been  double  interstitial  pregnancy. 

OVARIAN  PREGNANCY.  This  is  very  rare,  but  cannot  be  reason- 
ably doubted  after  the  cases  of  Leopold,  Martin,  Walter,  Maokeurodt, 
and  others.  Martin's  case,  reported  at  the  Brussels  Congress,  was  one 
in  which  the  subject  of  ovarian  pregnancy  had  cancer  of  the  cervix. 
The  explanation  of  the  origin  of  this  form  of  ectopic  gestation  is  that 
an  ovisac  rupturing  the  ovule  did  not  escape,  but  through  the  rent  in 
the  follicle  a  spermatozoid  entered  and  fecundation  followed.  The  liga- 
ment of  the  ovary  is  distinctly  shown  and  the  tube  does  not  participate 
in  the  formation  of  the  gestation  cyst. 

FIG.  162. 


OVARIAN  PREGNANCY,  LEFT  SIDE,  ONLY  PART  OF  THE  OVARY  PARTICIPATES  IN  THE 

GESTATION  CYST.    (From  WINCKEL.) 
a.  Ovarian  pregnancy,    b.  Left  tube.    c.  Uterus. 

TUBO-OVAEIAN.  Tubo-ovarian  pregnancy  may  result  from  congeni- 
tal or  acquired  union  between  the  abdominal  mouth  of  the  tube  and  the 
ovary ;  a  cyst  existing,  the  rupture  of  an  ovisac  into  it,  fecundation 
follows.  Such  pregnancy  has  in  rare  cases  gone  to  term.  The  usual 
course  of  an  ovarian  gestation  is  that  of  a  tubal  pregnancy. 

1  That  my  skepticism  in  regard  to  some  of  the  cases  of  interstitial  pregnancy  which  have  been 
reported  is  not  peculiar  is  shown  by  the  fact  that  Winckel  has  referred  to  one  of  them  "  as  more 
than  improbable,"  and  some  years  before  his  death  Dr.  Fordyce  Barker  requested  me  to  write  a 
criticism  of  another,  in  which  he  was  convinced  that  a  normal  gestation  had  been  ended  by  abor- 
tion from  the  erroneous  diagnosis  of  interstitial  pregnancy.  Yet  both  these  cases,  occurring  in 
this  country,  are  still  quoted  as  true. 


368 


THE  PATHOLOGY  OF  PREGNANCY. 


ABDOMINAL  PREGNANCY.  A  primary  abdominal  pregnancy  is  de- 
nied by  Mr.  Tait  on  the  ground  that,  even  if  an  impregnated  ovule 
drop  into  the  peritoneal  cavity,  the  digestive  power  of  the  peritoneum 
is  so  great  that  it  would  have  no  chance  of  development.  Neverthe- 
less, if  spermatozoids  can  live  for  months  in  the  abdominal  cavity  of 
the  frog,  is  it  not  possible  that  an  ovum  may  defy  peritoneal  digestion, 
and  its  development  take  place  in  the  peritoneal  cavity  ?  Moreover, 
what  happens  to  the  embryo  of  a  ruptured  ovum  does  not  necessarily 
occur  if  the  ovum  be  intact.  Hart  and  Carter,  however,  whose  re- 
searches will  be  referred  to  in  connection  with  intra-ligamentous  preg- 
nancy, state  that  a  purely  intra-peritoneal  variety  of  abdominal  preg- 
nancy is  yet  to  be  demonstrated.  Virchow  said  at  a  meeting  of  the 
Medical  Society  of  Berlin  that  he  could  not  believe  with  Olshuusen 
that  all  extra-uterine  pregnancies  were  tubal ;  that  such  an  opinion  was 
especially  difficult  to  admit  for  large  lithopsedions,  and  that  he  had 
seen  one  lasting  twenty-six  years  which  was  completely  outside  an  in- 
tact tube. 

What  is  called  secondary  abdominal  pregnancy  includes  those  cases 
in  which  an  ectopic  gestation  cyst,  usually  tubal,  at  least  primarily, 
opens  into  the  peritoneal  cavity,  and  the  development  of  the  foetus 
continues.  Mr.  Tait  asserts  that  this  pregnancy  results  from  rupture 
of  an  intra-ligamentous  cyst.  In  such  case  there  were  two  ruptures, 
one  primary,  that  is,  a  tubal  pregnancy  becomes  intra-ligamentous,  and 
the  other  secondary,  so  that  the  latter,  rupture  again  occurring,  is  con- 
verted into  abdominal. 

Kaltenbach  suggests  that  some  of  the  cases  called  abdominal  are 
only  partial — that  is,  tubo-abdominal. 

FIG.  168. 


UTERUS  AND  FCETUS  IN  A  CASE  OF  ABDOMINAL  PREGNANCY. 

It  is  generally  stated  that  in  abdominal  pregnancy  (Fig.  163)  the 
developing  ovum  causes  irritation  of  the  adjacent  parts,  and  a  cyst  is 
formed  of  pseudo- membranes.  "In  rare  instances  the  cyst  atrophies, 
or  is  not  formed,  and  the  ovum  is  free  in  the  abdominal  cavity ;  such 


ECTOPIC  PREGNANCY.  369 

cases  have  been  seen  by  Leeluyse,  Matecky,  Schreyer  and  others."  If 
a  sac  is  formed,  it  usually  contains  some  muscular  elements  derived 
probably  from  the  muscles  of  the  subserous  layer  of  the  pelvis.  The 
placenta  has  been  found  attached  to  the  uterus,  to  the  bladder,  or  to  die 
ovary ;  "  Sivard1  has  seen  it  attached  to  the  mesentery  and  colon  of 
the  left  side;  Courtail  to  the  omeutum  and  stomach;  Clarke  to  the 
kindneys  and  intestines;  Tilt  to  a  great  part  of  the  mesentery,  meso- 
colou,  portions  of  the  small  intestine,  and  to  the  two  or  three  superior 
lumbar  vertebrae ;  Baldwin,  Wilson  aud  KoeberlS  to  the  anterior  ab- 
dominal wall  in  the  line  of  incision  made  either  at  the  post-mortem 
examination  or  during  an  operation  for  gastrotomy." 

Abdominal  gestation  lasts  longer  than  any  other  ectopic  form.  In 
some  instances  the  foetus  develops  during  nine  months,  then  dies,  and 
it  may  be  retained  for  many  mouths,  or  even  many  years ;  in  one  in- 
stance the  pregnancy  lasted  fifty-four  years ;  a  still  longer  retention  is 
given  below. 

The  great  danger  of  ectopic  gestation,  as  has  been  pointed  out,  is 
hemorrhage,  and  if  the  patient  does  not  die  from  this,  subsequent  peri- 
toneal inflammation  may  lead  to  a  fatal  result. 

The  death  of  the  embryo  or  foetus,  which  is  a  favorable  event  in  all 
ectopic  gestations,  is  followed  by  changes  similar  to  those  which  occur 
after  death  in  intra-uteriue  pregnancy;  but  in  addition  to  these  changes 
the  foetus  may  be  converted  into  adipocere,  or  into  a  lithopsedion  ;2  the 
formation  of  a  lithopsedion  has  been  observed  in  pregnancy  in  a  rudi- 
mentary uterine  horn,  the  foetus  dying  at  five  months.  The  most  widely 
known  of  the  last  is  the  lithopsedion  of  Leinzell,  which  was  found  in 
one  of  the  tubes  upon  post-mortem  of  a  woman  ninety-two  years  old, 
who  had  carried  it  forty-six  years.  In  August,  1883,  Sappey  presented 
to  the  Paris  Academy  of  Sciences  the  membranes  and  foetus  which  had 
been  retained  fifty-six  years;  calcareous  incrustations  were  limited  to 
the  wall  of  the  cyst,  but  the  foetus  was  in  a  natural  attitude,  and  the 
skin,  superficial  organs  and  those  of  the  cavities,  the  muscles,  and  in 
fact  all  parts  of  the  body,  preserved  their  consistence,  suppleness,  and 
normal  color. 

Inflammation  and  suppuration  may  occur  in  the  foetal  cyst,  ending  in 
the  discharge  of  the  foetus  by  the  abdominal  walls,  by  the  bladder,  the 
vagina,  or  the  rectum.  According  to  Mattei,  the  first  is  the  most  fre- 
quent; according  to  Parry,  the  last.  In  one  instance  the  cyst  commu- 
nicated with  the  stomach ;  it  was  reported  by  Darby ;  "  the  cavity 
which  contained  the  child  hac\  opened  through  the  abdominal  wall ; 

1  Parry  on  Extra-uterine  Pregnancy. 

*  Lithopsedion,  literally  a  stone  child,  is  a  name  given  to  the  fcetus  when  calcification  has  oc- 
curred. Barnes  states  that  this  change  is  limited  to  the  membranes  and  sac,  the  shell  thus  formed 
preserving  the  fcetal  structures  but  little  changed.  But  this  is  only  one  of  three  forms.  Kuchen- 
meister  states  (Archiv  fur  Gynakql.,  1881)  that  the  ftetus  falling  into  the  abdominal  cavity,  in  con- 
sequence of  rupture  of  the  cyst,  is  mummified,  and  by  degrees  covered  by  a  calcareous  layer 
deposited  immediately  beneath  the  epidermis  ;  this  is  a  true  lithopjedion,  and  it  is  the  second  form. 
The  third  form  is  when  an  incrustation  involves  both  the  membranes  and  the  fcetus.  Sarraute 
(Archives  de  Tocologie,  March,  1885),  in  a  contribution  to  the  microscopic  study  of  lithopsedions, 
states  that  most  frequently  all  the  cavities  are  found  filled  with  calcareous  salts,  or  salts  derived 
from  fat ;  the  cartilages  and  bony  cavities  and  the  vertebne  are  infiltrated  with  calcareous  masses. 

"  The  oldest  known  case  of  lithopffidion  is  that  reported  by  Sens,  in  1582  ;  it  was  carried  twenty- 
eight  years.  This  case  inspired  Rousset  to  make  a  curious  poem,  in  which  he  presented  the  fol- 
lowing questions :  cur  nasci  potuerit  t  cur  per  vigenti  octo  annos  in  utero  retentus  non  putruerit  1  cur 
in  lapidem  obdurueril?" — Maygrier. 

24 


370  THE  PATHOLOGY  OF  PREGNANCY. 

when  Dr.  Darby  enlarged  the  orifice  and  extracted  the  fetus,  immedi- 
ately after  the  entire  contents  of  the  stomach  emptied  themselves  into 
the  cavity  of  the  cyst  through  a  ragged,  jagged  opening,  two  inches  in 
width." 

INTRA-LIGAMENTOUS  PREGNANCY.  The  origin  of  this  variety  of 
ectopic  gestation  has  been  given,  and  its  possible  termination  in  a  sec- 
ondary abdominal  pregnancy  by  rupture  into  the  peritoneal  cavity, 
should  the  fetus  live,  has  been  stated.  While  in  a  great  majority  of 
cases  the  embryo  or  fetus  perishes,  the  tube  rupturing  between  the  folds 
of  the  broad  ligament,  in  a  few  pregnancy  may  continue  for  some 
weeks,  the  fetus  then  dying  and  suppuration  follow,  or  it  may  continue 
until  term.  The  changes  that  occur  in  the  developing  ovum  in  regard  to 
the  peritoneum  are  of  great  interest,  and  were  first  made  known1  through 
the  study  of  frozen  sections  by  Hart  and  Carter  ;  these  sections  were  of 
two  specimens — the  one  a  four  and  a  half  months'  extra-uterine  preg- 
nancy, in  situ  in  the  bony  pelvis ;  the  other  an  entire  cadaver  with 
advanced  abdominal  gestation.  From  the  report  of  this  examination 
the  following  passages  are  taken  : 

"  The  consideration  of  these  two  sections  shows,  therefore,  a  special  phase  in 
the  development  of  extra-uterine  gestation.  They  demonstrate  that  a  Fallopian 
tube  pregnancy  may  develop  between  the  layers  of  the  broad  ligament,  and  may 
continue  this  extra-peritoneal  growth,  stripping  off  the  peritoneum  from  the 
uterus,  bladder,  and  pelvic  floor  until  it  becomes  in  great  degree  surrounded  by 
a  peritoneal  capsule  derived  from  these  organs.  All  this  is  done  without  any 
actual  intra-peritoneal  invasion.  The  placenta  in  the  advanced  gestation  case 
is  attached  in  front  to  the  extra-peritoneal  connective  tissue,  the  veins  there  en- 
larging and  acting  like  uterine  veins. 

"  In  this  special  cadaver,  therefore,  the  gestation  began  probably  in  the  right 
Fallopian  tube,  developed  into  the  layers  of  the  broad  ligament,  and  grew  extra- 
peritoneally,  lifting  up  the  peritoneum  on  the  right  side  of  the  middle  line  both 
anteriorly  and  posteriorly,  and  also  stripping  the  posterior  uterine  wall  and  upper 
part  of  the  anterior  wall. 

"We  have  here  what  may  be  termed  a  slow  displacement  of  the  placenta.  At 
first  it  lay  in  the  Fallopian  tube,  but  the  growing  ovum  has  slowly  pushed  it  up 
(a  process  attended  with  blood  extravasation)  from  the  pelvis  to  the  abdominal 
cavity,  until  at  last  its  upper  edge  is  about  ten  inches  from  its  original  site. 
Part  of  this  is  due  to  growth,  of  course." 

The  authors  suggest  that  this  variety  of  pregnancy  should  be  termed 
subperitoneo-abdominal. 

DIAGNOSIS.  It  is  by  careful  study  of  physiological  and  pathological 
symptoms  that  the  diagnosis  of  ectopic  gestation  is  made.  In  the  first 
place,  the  fact  of  probable  pregnancy  is  to  be  established  ;  it  is  not  nec- 
essary to  detail  local  changes  in  the  sexual  organs  and  the  reflex  phe- 
nomena indicative  of  this  condition.  Next,  we  endeavor  to  learn  that 
the  uterus  is  not  the  seat  of  this  pregnancy.  This  organ,  though  as  a 
rule  increased  in  size,  is  not  so  large  as  it  would  be  at  the  supposed 
period  of  gestation.  Hecker  has  stated  that  the  uterine  cavity  may  be 
increased  to  fifteen  centimetres,  or  more  than  five  inches.  There  is 
found  adjacent  to  it  a  growing,  usually  pear-shaped,  somewhat  sensitive 
tumo'r,  not  solid,  and  with  little  mobility.  Menstruation  having  been 
suppressed  at  one  period,  possibly  two,  there  occurs  a  profuse  and  pain- 

1  Transactions  of  the  Edinburgh  Obstetrical  Society,  vol.  xii. 


ECTOPIC  PREGNANCY.  371 

ful  flow  with  the  discharge  of  fragments  of  decidua,  microscopic  exam- 
ination of  which  will  be  necessary  to  determine  their  character.  Gus- 
serow,  in  a  case  reported  by  Glahn,  in  order  to  assist  in  the  diagnosis, 
used  a  curette  for  the  removal  of  decidua  from  the  uterus.  Should  the 
pregnancy  continue  until  the  sounds  of  the  foetal  heart  can  be  heard, 
and  ballottement  is  available — such  prolongation  of  ectopic  pregnancy, 
it  must  be  remembered,  is  exceptional — the  question  is  more  readily 
answered.  So,  too,  if  the  practitioner  has  sufficient  evidence  to  justify 
dilating  the  cervical  canal,  and  the  use  of  finger  and  sound  to  explore 
the  cavity  of  the  uterus,  the  absence  of  intra-uterine  pregnancy  can  be 
conclusively  proved,  and  therefore  the  ovum,  provided  the  woman  is 
pregnant,  must  be  ectopic. 

The  diagnosis  of  ectopic  gestation  in  the  first  months  has  been  a  subject  of  no 
little  controversy.  Spiegelberg  has  said  that  a  diagnosis  is  all  but  impossible 
during  the  first  three  or  four  months,  and  can  only  be  arrived  at  in  exceptional 
cases ;  and  Bandl  suggests  that  the  practitioner  will  do  well  not  to  make  an 
absolute  diagnosis  of  extra-uterine  pregnancy  until  he  can  appreciate  the  certain 
signs  of  foetal  life,  active  movements  and  the  heart-sounds.  On  the  other  hand, 
it  has  been  claimed  that  the  early  diagnosis  of  an  ectopic  is  easier  than  of  a 
normal  pregnancy.  The  question  is  very  fully  discussed  by  Strahan,  whose  valu- 
able monograph1  can  be  consulted  by  the  practitioner  with  benefit.  Winckel 
gives  the  following  as  probable  symptoms  which  "  in  their  entirety  permit  a  cer- 
tain diagnosis,  especially  if  their  progressive  increase  is  established  by  repeated 
observations :" 

1.  The  cessation  of  previously  normal  menses. 

2.  Hyperaemia  and  secretion  of  the  breasts. 

3.  Hyperaemia  and  livid  coloring  of  the  vulva  and  vagina,  which  increases 
toward  the  portio  vaginalis. 

4.  The  strongly  pulsating  arteries  in  the  vault  of  the  vagina. 

5.  The  softening,  enlargement  and  displacement  of  the  uterus. 

6.  The  clearly  defined  and  growing  tumor. 

7.  The  vascular  murmur  or  souffle  above  the  symphysis,  which  is  heard  at 
rather  an  early  period. 

Dr.  Reeve  in  an  article2  upon  the  subject,  in  which  it  is  asserted  that  a  diag- 
nosis "  can  be  made  at  an  earlier  period  than  in  a  normal  pregnancy,"  refers  to 
cases  of  its  having  been  made  as  early  as  the  eighth  and  fifth  week,  and  gives 
the  following  classification  and  enumeration  of  symptoms  : 

"  I.  Suggestive.— a.  The  general  and  reflex  symptoms  of  pregnancy,  especially 
if  the  pregnancy  had  occurred  after  a  considerable  period  of  barrenness. 

"  b.  Disordered  menstruation,  especially  metrorrhagia  coincident  with  symp- 
toms of  pregnancy ;  gushes  of  blood  accompanied  with  severe  pelvic  pains. 

"c.  Severe  pain  in  the  pelvis  ;  attacks  of  pelvic  pain  followed  by  tenderness  in 
either  iliac  region,  and  other  symptoms  of  pelvic  inflammation. 

"  II.  Presumptive. — a.  The  existence  of  a  tumor :  this  tumor  presenting  the 
characteristics  of  a  tense  cyst,  sensitive  to  touch,  actively  pulsating;  steady  and 
regular  growth  of  the  tumor  to  be  ojbserved. 

"b.  The  os  uteri  patulous,  the  uterus  displaced  and  empty. 

"  III.  Certain. — a.  Paroxysms  of  violent  and  overwhelming  pain  in  the  pelvis, 
with  general  symptoms  of  collapse. 

"  b.  Expulsion  of  the  decidua."  .  „• 

The  employment  of  the  uterine  sound  is  permitted  only  when  there  is  a  proba- 
ble evidence  of  ectopic  gestation.  Kaltenbach  warns,  if  the  sound  is  used, 
against  the  danger  of  perforating  the  uterus  because  of  its  tissues  being  less  firm. 

The  abdominal  tenderness  may  be  so  great,  especially  in  an  advanced  ectopic 
gestation,  that  no  satisfactory  conclusion  can  be  reached  without  the  patient 
is  anaesthetized. 

1  The  Diagnosis  and  Treatment  of  Extra-uterine  Pregnancy,  1889. 

2  American  Journal  of  the  Medical  Sciences,  July,  1889. 


372  THE  PATHOLOGY  Of1  PREGNANCY. 

DIAGNOSIS  OF  RUPTURE.  The  diagnosis  of  rupture  of  a  tubal  preg- 
nancy is  made  by  learning  of  severe  pain  in  the  lower  part  of  the 
abdomen  or  pelvis,  suddenly  occurring,  possibly  when  the  patient  was 
making  some  exertion,  straining,  stooping,  lifting  a  weight,  etc.,  and 
this  is  followed  by  faintuess  or  fainting  and  collapse ;  the  skin  is  cold, 
the  pulse  feeble  and  frequent,  and  there  is  acute  anaemia.  "  The  diag- 
nosis of  tubal  pregnancy  at  the  time  of  rupture  may  be  made  with 
certainty  seven  times  out  of  eight,  and  may  be  guessed  at  in  the  eighth 
instance.  The  symptoms  are  too  serious  to  be  lightly  regarded  at  any 
time,  and  are  practically  coincident  with  those  of  pelvic  heematocele. 
If  the  rupture  takes  place  into  the  broad  ligament,  they  are  the  symp- 
toms of  extra-peritoneal  hsematocele.  If  the  rupture  takes  place  into 
the  peritoneal  cavity,  they  are  the  characteristic  and  most  serious  group 
which  belongs  to  iutra-peritoueal  hsematocele."  (Tait.) 

PROGNOSIS.  Martin1  states  that  the  prognosis  of  ectopic  gestation 
has  materially  improved  uuder  the  influence  of  a  better  diagnosis  and 
treatment.  He  gives  the  following  statistics  :  255,  expectant  treatment, 
36.9  recoveries,  63.1  deaths;  515,  operative  treatment,  76.7  recoveries, 
23.3  deaths. 

TREATMENT.  Admitting  the  diagnosis  of  an  ectopic  pregnancy, 
almost  certainly  tubal,  before  rupture,  what  course  should  be  pursued? 
Foeticide,  or  by  abdominal  section  removal  of  the  gestation  cyst?  The 
foeticidal  means  which  have  been  used  are  evacuation  of  the  amnial 
liquor,  morphine  injection,  and  electricity.  The  first  is  uncertain  and 
dangerous,  and  is  now  without  an  advocate.  Joulin  in  18632  proposed 
injecting  strychnine  or  atropine  into  the  foetal  cyst,  and  Friedrich  in 
18643  injected  a  solution  of  morphine  in  a  tubal  pregnancy.  Since 
then  the  method  has  been  employed  by  Koeberle,  Rennert,4  Taruier5 
and  Wiuckel.  Winckel  always  injects  0.03  gramme,  under  the  usual 
precautions,  through  the  abdominal  wall,  at  intervals  of  six  to  eight 
days;  two  or  three  injections  generally  suffice.  He  claims  that  this 
method  of  killing  the  foetus  may  be  practised  successfully  up  to  the 
end  of  the  fourth  and  even  during  the  fifth  month  ;  and  also  that  it  is 
very  easy  of  performance  and  perfectly  innocuous  to  the  mother. 

Winckel  states  that  there  are  now,  1893,  sixteen  cases  of  ectopic  ges- 
tation, ten  of  them  his  own,  treated  by  injection  of  morphine  into  the 
gestation  cysts,  three  of  the  patients  dying,  or  19  per  cent.  He  re- 
gards the  treatment  as  easy,  and  without  danger  to  the  mother ;  he 
states  that  the  swelling  perceptibly  lessens  in  a  short  time,  and  as  a 
rule  completely  disappears  in  from  six  to  twelve  months. 

THE  USE  OF  ELECTRICITY.  According  to  Depaul,  Dubois  first  ad- 
vised electricity  to  kill  the  foetus  in  normal  pregnancy  when  grave  acci- 
dents threatened  the  life  of  the  mother.  Bachetti,  of  Pisa,  in  1857,  suc- 
cessfully employed  electricity  in  a  tubal  pregnancy  of  the  third  month  ; 
two  long  needles  connected  with  an  electro-magnetic  machine  were  in- 
troduced into  the  cyst.  In  1865  Braxton  Hicks  attempted  to  destroy 
the  foetus  in  an  extra-uterine  gestation  of  three  months  and  a  half  by 

i  Proceedings  of  Brussels  Congress.    •  2  Traite  corap'.et  d'Accouchements. 

«  Virchow's  Archiv,  1864.  i  Arch.  f.  GynSkol.,  1884-5. 

5  Both  in  the  priginal  and  in  Dr.  Edgar's  translation  of  "  Wiuckel,"  this  name  is  given  as  Four- 
nier— evidently  a  typographical  eiror. 


ECTQPIC  PREGNANCY.  373 

two  applications  of  the  galvanic  current  at  an  interval  of  ten  days,  but 
failed.  In  1869,  J.  G.  Allen,  of  Philadelphia,  succeeded  by  faradiza- 
tion in  arresting  pregnancy. 

This  treatment  of  ectopic  gestation  has  been  so  frequently  used  by 
American  practitioners,  so  little  by  others,  that  it  is  often  called  the 
American  method.  The  galvanic  current  has  been  selected  in  some 
cases,  and  abroad — not  in  this  country,  I  believe,  a  single  time — gal- 
vano-puncture,  but  general  preference  is  given  to  the  faradic  current. 
An  ordinary  battery,  with  single  cell,  is  employed ;  the  negative  pole 
is  introduced  in  the  vagina  or  in  the  rectum  as  near  the  tumor  as  it  can 
be,  while  the  positive  pole,  connected  with  a  dampened  sponge,  is  placed 
upon  the  abdomen.  A  current,  not  so  strong  as  to  cause  the  patient 
any  great  distress,  is  passed  through  the  tumor  for  ten  minutes ;  this  is 
repeated  each  day  until  the  tumor  ceases  to  grow ;  four  or  five  applica- 
tions probably  will  be  necessary.  Blackwood,  of  Philadelphia,  who 
has  had  a  large  experience  with  this  mode  of  destroying  the  life  of  the 
embryo  or  foetus,  prefers  a  strong  current  continued  for  an  hour,  but  he 
is  probably  alone  in  this  preference.  The  galvanic  current  has  been 
advised  by  Rockwell,  and  has  been  successfully  used  in  New  York  in 
several  cases,  though  the  method  has  differed,  in  some  the  interrupted 
and  in  others  the  continuous  being  employed.  Rockwell1  prefers  the 
former,  the  strength  being  from  10  to  20  milliamperes. 

No  impartial  reader  of  the  reports  of  cases  by  competent  and  reput- 
able men  can  doubt  that  some  ectopic  gestations  have  by  this  means 
been  conducted  to  a  favorable  termination ;  that  is  to  say,  the  preg- 
nancy was  arrested,  and  the  patient  suffered  no  subsequent  or  serious 
inconvenience. 

Malcolm  McLean  asserts2  that  "in  a  vast  majority  of  cases  the 
results  of  electrical  treatment  are  good,  and  do  not  leave  the  woman  in 
a  worse  condition." 

Brothers,  of  New  York,  an  ardent  advocate  of  the  electric  treatment 
of  ectopic  gestation,  has  recently  said3  that  "  beyond  one  death  in  seventy- 
eight  cases  no  injury  has  ever  been  done  by  the  use  of  electricity,  and 
when  it  has  been  abandoned  for  laparotomy  no  harm  was  done  by  the 
previous  treatment." 

Those  who  substitute  death  of  the  ovum  for  death  of  the  foetus  seem 
to  assume  a  point  in  dispute,  denying  the  possible  growth  of  the  placenta 
after  fbeticidal  means  have  been  successfully  used.  That  in  some  cases 
the  placenta  continues  to  grow  does  not  rest  alone  upon  Mr.  Tait's  as- 
sertion. The  same  statement  is  made  by  Hart  and  Barbour,  Manual 
of  Gynecology.  Champneys  and  Thornton  concede  the  fact,  London 
Obstetrical  Society's  Transactions,  vol.  xxix.  Bandl,  in  his  well-known 
monograph  on  extra-uterine  pregnancy,  refers  to  the  placenta  develop- 
ing for  some  time  after  the  foetus  is  dead.  Dole'ris,  Nouv.  Arch. 
d'Obstet.  et  de  Gyn.,  1888,  says  that  when  the  foetus  dies  in  ectopic  ges- 
tation "the  placenta  in  these  cases  often  continues  to  vegetate,  for 
habitually  it  does  not  atrophy  until  the  term  of  gestation  has  been 
passed  or  attained." 

1  American  System  of  Gynecology.  2  American  Journal  of  Obstetrics,  1892. 

8  Ibid.,  1894.    The  writer  also  asserts  that  in  five  cases  electricity  caused  the  transfer  of  the  ovum 
into  the  uterine  cavity.    In  regard  to  some  of  these  cases  skepticism  is  wiser  than  faith. 


374  THE  PATHOLOGY  OF  PREGNANCY. 

Doubtless  too  much  has  been  claimed  for  electricity,  and  even  some 
of  its  earnest  advocates  abate  their  zeal  and  positiveness  of  utterance. 
One  of  them,  well  known  for  his  honesty  and  ability,  in  1887  stated 
that  '  it  was  safe  to  predict  that  electricity  will  yet  become  the  only 
method  of  treatment  in  ectopic  gestation  prior  to  the  rupture  of  the 
cyst,  and  that  through  this  means  the  dreadful  mortality  from  gestation 
of  this  nature  will  be  reduced  by  fully  three-quarters."  He  also  stated 
that  the  method  is  applicable  to  every  form  of  ectopic  gestation  prior 
to  the  middle  or  end  of  the  fourth  month,  and  prior  to  rupture  of  the 
cyst.  In  1889  the  same  gentleman  said :  "  Electricity,  then,  under 
the  third  month,  with  absence  of  symptoms  of  rupture,  I  would  advo- 
cate. At  most  it  can  do  no  harm,  and  it  may  do  good." 
—^-TREATMENT  BY  ABDOMINAL  SECTION.  Tait  remarks  that  "  If  I 
ever  should  make  a  diagnosis  of  tubal  pregnancy  before  rupture,  I 
should  advise  its  immediate  removal  by  abdominal  section."  Strahan 
asserts  that  "  the  proper  treatment  of  extra-uterine  gestation  in  the  pre- 
ruptured  stage,  whenever  diagnosed,  or  suspected  with  great  probability 
rather,  is  instant  abdominal  incision  and  removal  of  the  entire  trouble." 
Werth1  believes  that  an  ectopic  pregnancy  ought  to  be  regarded  as  a 
malignant  tumor  demanding  prompt  removal ;  in  an  interstitial  preg- 
nancy a  pedicle  should  be  made  of  the  lower  part  of  the  uterus,  and 
hysterectomy  done. 

When  one  realizes  by  witnessing  how  suddenly  in  the  midst  of  ap- 
parent health  a  gestation  cyst  may  rupture,  and  how  swiftly  death 
follows  in  almost  all  cases  not  rescued  by  a  surgical  operation ;  and  then 
upon  opening  the  abdomen  he  finds  sometimes  from  a  rent  compara- 
tively small  copious  bleeding  has  occurred,  he  will  hesitate  to  advise 
in  an  ectopic  gestation,  the  diagnosis  of  which  is  clear,  any  delay  in  its 
removal,  even  though  the  pregnancy  may  not  have  lasted  a  month. 

TREATMENT  OF  RUPTURE.  Absolute  rest  in  a  horizontal  position, 
sulphuric  ether  hypodermatically,  alcoholic  stimulants  and  the  ice-bag, 
or  a  sack  of  sand  to  the  lower  part  of  the  abdomen,  constitute  the  most 
important  part  of  the  treatment,  which  seeks  to  arrest  the  flow  of  blood 
and  to  bring  about  reaction.  As  soon  as  the  patient  reacts,  the  general 
rule  is  to  perform  laparotomy ;  some,  indeed,  would  operate  immedi- 
ately. 

But  take  the  case  of  a  patient  who  has  passed  some  days  since  the 
accident,  all  symptoms  being  favorable,  the  retro-uterine  haematocele 
gradually  lessening,  the  temperature  normal,  and  only  slight  discom- 
fort or  none  at  all  felt.  I  believe  with  Winckel,  Ahlield,  and  some 
others  that  operative  treatment  under  such  circumstances  is  not  in- 
dicated. If,  however,  suppuration  occur,  then  this  treatment  must  be 
promptly  employed. 

It  should  be  remembered  that  laparotomy,  now  so  generally  resorted 
to  in  rupture  of  an  ectopic  pregnancy  cyst,2  was  advised  many  years  ago 
by  the  late  Dr.  Stephen  Rogers,  of  New  York. 

When  gestation  has  been  half-completed,  the  child  living,  most 
advise  immediate  operation,  having  regard  only  for  the  mother's  life. 

1  Beitrage  zur  Anatomic  und  zur  operativen  Behandlung  der  Extrauterin-Schwangerschaft, 
Stuttgart,  1887. 

2  Transactions  of  American  Medical  Association,  vol.  xviii. 


ECTOPIC  PREGNANCY.  375 

This  position  has  recently  been  controverted.  Thus  G.  Rein,1  of  Kieff, 
who  believes  primary  abdominal  pregnancy  sometimes  occurs,  asserts 
that  the  conservative  principle  should  be  applied  in  some  cases  of 
ectopic  gestation,  and  that  we  have  not  then  the  moral  right  to  destroy 
the  infant.  If  the  pregnancy  has  passed  one-half,  and  the  proof  that 
the  child  is  living  is  certain,  the  conservative  method  is  absolutely 
indicated,  and  we  ought  not  to  regard  the  ovum  as  a  dangerous,  still  less 
a  malignant  disease.  Placing  our  patient  in  the  most  favorable  circum- 
stances for  immediate  laparotomy,  if  this  should  be  necessary,  we  wait 
until  the  infant  has  the  best  chance  of  living  outside  the  maternal 
organism — that  is  to  say,  the  ninth  month  of  pregnancy. 

If  the  normal  period  of  pregnancy  has  been  reached,  abdominal 
section  is  done  for  saving  the  child's  life,  and  there  is  also  a  reasonable 
probability  of  saving  the  life  of  the  mother  with  certain  improvements 
in  the  method  of  operating  and  subsequent  treatment — certainly  her 
chances  of  recovery  are  probably  not  lessened  but  rather  improved  by 
a  properly  performed  operation.  The  treatment  of  the  placenta  has 
presented  the  most  serious  difficulty.  Of  course,  if  it  can  be  removed 
with  the  foetal  cyst  it  is  a  fortunate  thing  for  patient  and  operator ;  it 
is  rare,  however,  that  perfect  heemostasis  can  be  secured,  as  in  Eastman's 
case,  or  as  in  the  cases  of  Martin  and  of  Breisky. 

Tait  in  two  cases  was  able  to  remove  the  placenta,  tying  a  large 
pedicle,  the  remains  of  the  tube  and  broad  ligament,  which  contained 
the  chief  blood  supply  to  the  organ,  and  in  each  case  the  mother  as 
well  as  the  child  was  saved.  But  such  cases  are  probably  exceptional. 
There  may  be  no  fcetal  cyst,  and  then  after  the  removal  of  the  foetus 
the  cord  is  tied  and  divided,  and  its  placental  end  is  left  hanging  out 
of  the  abdominal  wound,  a  draining-tube  being  placed  by  its  side. 
Tedious  suppuration  follows  this  method,  and  the  woman  may  perish 
of  septic  infection  more  than  a  month  after  the  operation,  as  in  Champ- 
ney's  case,  the  disease  occurring  when  convalescence  seemed  established. 
Tait  proposes  cutting  off  the  cord  near  the  placenta,  closing  the  sac,  and 
thus  leaving  the  placenta  to  be  absorbed. 

Should  the  foetus  be  dead,  perishing  in  the  latter  half  of  pregnancy 
or  after  false  labor,  which  occurs  in  cases  of  ectopic  gestation  at  the 
normal  period  of  pregnancy,  the  chances  of  its  conversion  into  a  harm- 
less lithopffidion  are  slight,  and  the  probabilities  of  painful  and  pro- 
longed suppuration  with  the  passage  of  foetal  debris  through  the  rectum, 
the  vagina,  the  bladder,  or  the  abdominal  wall,  imperilling  the  mother's 
life — in  many  instances  she  parishes — are  so  great  that  active  inter- 
ference is  indicated.  Therefore  by  abdominal  section,  rarely  by  ely- 
trotomy,  removal  of  the  foetus  is  advisable.  Unless  the  indications 
are  urgent,  the  operation  is  delayed  until  the  placenta  has  probably 
undergone  such  changes  that  its  removal  may  be  accomplished  without 
serious  hemorrhage. 

Elytrotomy  in  ectopic  gestation  Winckel  restricts  to  cases  in  which 
suppuration  has  occurred  and  perforation  of  the  vagina  is  threatened. 
Nevertheless  he  quotes  two  cases  in  which  the  posterior  vaginal  vault 

1  Proceedings  of  the  Brussels  Congress. 


370 


THE  PATHOLOGY  OF  PREGNANCY. 


was  opened,  and  in  each  case  a  child  extracted  by  forceps  ;  one  of  the 
children  lived. 

Kaltenbach  advised  in  case  of  suppuration  in  the  cyst  of  an  Sutra- 
ligamentous  pregnancy,  treating  it  as  an  open  wound,  and  filling  it  with 
cotton  covered  with  tannin  and  salicylic  acid. 

A  similar  treatment  was  employed  by  him  in  those  cases  in  which  the 
foetal  cyst  and  placenta  could  not  be  removed.  The  placenta  under  this 
treatment  shrinks  into  a  dry  leather-like  mass,  and  in  eight  or  ten 
days  can  be  removed  without  bleeding. 


FIG.  164. 


GESTATION  IN  A  RUDIMENTARY  HORN  OF  THE  UTERUS. 

A.  Developed  right  horn.  B.  Rudimentary  horn,  with  a  rent  through  which  the  embryo  had 
escaped.  1.  Right  Fallopian  tube.  2.  Left  Fallopian  tube.  3.  Left  ovary.  4,  5.  Right  ovary  and 
corpus  luteurn.  6.  Round  ligament. 

PREGNANCY1  IN  A   RUDIMENTARY   HORN   OF   THE  UTERUS.      The 

symptoms  of  cornual  pregnancy  are  those  of  tubal,  and  the  treatment 
in 'no  respect  differs. 

ECTOPIC  DEVELOPMENT  OF  THE  PLACENTA — Vicious  INSERTION 
OF  THE  PLACENTA — PLACENTA  PRJEVIA. — Benjamin  Pugh,  in  his 
treatise  upon  Midwifery,  1754,  remarked  that  "the  placenta  sometimes 
loosens  before  the  membranes,  which  contain  the  waters,  are  broke,  and 
by  the  child's  turning  itself,  it  is  sometimes  found  to  present  at  the 
mouth  of  the  womb,"  etc.  This  was  the  explanation  generally  given 
by  obstetricians  of  those  cases  in  which  the  placenta  was  found  at  the 
mouth  of  the  womb  previous  to  the  birth  of  the  child.  Nevertheless, 
Paul  Portal,  in  1685,  had  spoken  of  firm  adherences  between  the  pla- 
centa and  parts  contiguous  to  the  mouth  of  the  wornb ;  and  Schlacher, 
in  1709,  had  given  an  anatomical  demonstration  of  this  condition  upon 
the  body  of  a  woman  dead  from  uterine  hemorrhage.  Rigby,  whose 
admirable  Essay2  was  published  in  the  latter  half  of  the  eighteenth 

1  An  interesting  report  of  a  case  successfully  operated  upon  by  the  late  Dr.  Angus  MacDonald 
will  be  found  in  the  tenth  volume  of  the  Edinburgh  Obstetrical  Society's  Transactions.     Dr.  Mac- 
Donald  with  the  report  has  also  given  a  good  resume  of  the  cases  observed  up  to  that  time. 

2  An  Essay  on  the  Uterine  Hemorrhage  which  precedes  the  Delivery  of  the  Full-grown  Foatus, 
illustrated  with  cases.    The  fourth  edition  was  issued  in  1789. 


ECTOPIC 


century,  made  a  distinction  which  is  still  recognized,  between  accidental 
and  unavoidable  uterine  hemorrhage,  the  former  occurring  when  the 
placenta  occupies  its  normal  position,  the  latter  when  u  it  is  fixed  to  that 
part  of  the  womb  which  always  dilates  as  labor  advances."  It  Avill  be 
observed  by  the  words  just  quoted  from  Rigby  that  those  authors  who 
have  attributed  unavoidable  hemorrhage,  occurring  in  pregnancy,  to  the 
abnormal  situation  of  the  placenta,  have  no  authority  from  him  for  such 
use  of  the  word  unavoidable.  Rigby's  definition  of  placenta  pnevia  is 
that  which  is  in  accordance  with  the  most  recent  knowledge.  For  ex- 
ample, Spiegelberg  has  said  that  the  placenta  is  pr<evia  when  a  greater 

FIG.  165. 


COMPLETE  PLACENTA  PR^EVIA;  Os  PARTLY  OPEN.    (From  RAMSBOTHAM.) 

or  less  part  of  it  is  situated  in  that  part  of  the  lower  segment  of  the 
uterine  body  which  must  be  stretched  in  labor.  He  further  compares 
this  portion  of  the  uterus  to  a  hemisphere  which  during  parturition  must 
be  converted  into  a  cylindrical  canal.  The  lower  segment  of  the  uterus 
is  bounded  below  by  the  internal  os,  and  its  upper  limit  is  two  or  two 
and  one-half  inches,  measured  along  the  uterine  wall,  above.  This 
must  be  changed  into  a  cylindrical  canal  having  a  diameter  of  eleven 
centimetres,  or  four  and  one-half  inches. 


378 


THE  PATHOLOGY  OF  PREGNANCY. 


VARIETIES.  It  has  been  customary  to  describe  these  as  central,  par- 
tial, marginal,  and  lateral.  But  I  think  it  better  to  have  only  two 
varieties,  complete  and  partial.  A  central  implantation  of  the  placenta 
— that  is,  the  centre  of  the  placenta  corresponding  with  the  centre  of  the 
os  uteri — is  exceedingly  rare,  and  therefore  should  not  be  made  a  variety, 
but  is  included  under  the  term  complete  ;  while  partial  placenta  praevia 
embraces  all  cases  in  which  the  placenta  is  in  whole  or  in  part  attached 
to  some  portion  of  the  lower  uterine  segment,  whether  it  extends  par- 
tially over  the  os,  is  at  its  margin,  near  to  it,  or  somewhat  remote. 


Flrt.  ICG. 


PARTIAL  PLACENTA  PR.EVIA.    (From  RAMSBOTHAM.) 
The  os  partly  dilated ;  the  membranes  entire. 

FREQUENCY.  1  in  573,  Johnson  and  Sinclair;  1  in  575,  Guy's 
Hospital  Lying-in  Charity,  Galabin  ;  1  in  1000,  Spiegelberg.  In  add- 
ing up  the  statistics  given  by  Depaul,  from  Ramsbotham,  Schwartz, 
Arneth,  Klein,  Collins,  MacClintock,  aud  Hardy,  and  from  the  Ma- 
ternity at  Wurzburg,  and  the  Hopital  des  Cliniques  de  la  FacultS  de 
Parts,  amounting  in  all  to  nearly  600,000, 1  find  the  proportion  of  cases 
of  placenta  praevia  1  to  a  little  more  than  1200.  Winckel  makes  the 
proportion  1  in  1500;  Kalteubach  1  in  1500-1600. 

ETIOLOGY.  Placenta  praevia  occurs  more  frequently  in  multigravidae 
than  in  primigravidae,  in  the  poor  than  in  the  rich,  either,  as  suggested 
by  Spiegelberg,  because  of  hard  work  in  the  early  part  of  pregnancy,  or 
more  probably  from  subiuvolution  of  the  uterus.  Anomalies  of  the 
uterus  or  neoplasms  predispose  to  it;  hence  it  is  more  frequent  in  uterus 
unicornis  aud  bicornis,  aud  in  carcinoma  and  myoma.  Ingleby  has  re- 


ECTOPIC  PREGNANCY. 


379 


corded  two  cases  in  which  the  oviducts  entered  the  uterus  near  the 
internal  os ;  one  of  the  women  had  placenta  pnevia  three,  and  the  other 
ten  times. 

It  is  probable  that  the  most  important  of  causes,  and  to  which  some 
of  those  that  have  been  mentioned  conduce,  is  endometritis  with  catarrh. 

FIG.  167. 


PARTIAL  PLACENTA  PR.EVIA.    (From  RAMSBOTHAM.) 

The  same  case  after  rupture  of  the  membranes ;  the  head  pressing  on  the  placenta,  prevents 

further  loss  of  blood. 

Reamy  has  suggested  that  the  prsevial  implantation  of  the  placenta  may  origi- 
nate in  sexual  intercourse  occurring  fifteen  or  sixteen  days  after  menstruation, 
the  delay  being  with  the  hope  of  preventing  conception,  and  Pinard  asks  if 
travelling  early  in  pregnancy,  with  consequent  jolting  in  carriages  or  cars,  may 
not  be  a  cause.  Osiander  taught  that  lying  upon  the  back  tended  to  cause 
attachment  of  the  placenta  at  the  fundus,  while  standing  or  sitting  after  coition 
favored  implantation  over  the  os.  Miiller,  in  his  monograph  upon  Placenta 
Prcevia,  states  that  some  accuse  conception  during  menstruation,  and  others 
coition  when  the  uterus  has  a  more«vertical  position,  and  hence  when  the  parties 
are  standing,  as  causes. 

Wiuckel  states  that  plural  pregnancy  predisposes  to  the  anomaly, 
it  being  then,  according  to  his  experience,  four  times  more  frequent. 
In  1890  Hofmeier1  concluded,  from  the  examination  of  the  uterus  of  a 
woman  pregnant  with  twins,  and  dying  in  the  fifth  month,  that  in 
most  if  not  all  cases  placenta  prsevia  originated  from  the  development 
of  the  placenta  within  the  reflexa  of  the  lower  pole  of  the  ovum.  In 

1  Zur  Anatomie  und  Aetiologie  der  Placenta  Prsevia. 


380 


THE  PATHOLOGY  OF  PREGNANCY. 


FIG.  168. 


ILLUSTRATING  HOFMEIEE'S  THEORY  OF 
PLACENTA  PR^VIA. 


the  illustration  it  will  he  observed  that  part  of  the  reflexa  upon  which 
the  placenta  has  formed  is  not  yet  united  with  the  vera. 

Kalteubach  has  made  the  following  statement:  Through  prepara- 
tions made  from  the  early  period  of  pregnancy  Hofmeier  and  I  have 

shown  that  in  placenta  praevia  the  placen- 
tal  development  takes  place  within  the 
reflexa  of  the  under  pole  of  the  ovum. 
The  under  surface  of  the  pnevial  placenta 
is  covered  with  smooth  reflexa  that  later 
will  unite  with  the  vera  lying  opposite. 

The  views  of  Hofmeier  and  Kalten- 
bach  have  been  accepted  by  several  emi- 
nent German  obstetricians,  such  as  Ols- 
hausen  and  Martin,  but  rejected  by  others, 
as  AVinckel  and  Ahlfeld. 

Hart  holds1  that  there  is  primary  im- 
plantation of  the  ovum  low  down,  or  even 
over  the  os  internum.  The  hypothesis 
upon  which  he  proposes  to  explain  this 
low  implantation  "  is  that  the  human 
ovum  can  graft  only  on  a  surface  de- 
nuded of  epithelium,  and  that  it  does  not 
graft  thus,  but  in  some  part  of  the  uter- 
ine cavity  where  the  epithelium  has  been  removed  by  menstruation. 
If,  then,  the  ovum  does  not  meet  with  the  connective-tissue  surface 
until  it  has  passed  low  down  in  the  uterine  cavity,  some  form  of  pla- 
centa prsevia  will  happen." 

Barnes  states2  that  the  "  ovum  sought  attachment  to  healthy  endo- 
metrium  ;  if  the  upper  part  was  diseased,  the  ovum  would  be  apt  to 
stretch  lower,  that  is,  within  the  lower  zone." 

^Barnes  teaches  that  the  site  of  safe  and  most  natural  attachment  of 
the  placenta  is  in  the  fundal  zone,  as  shown  in  the  diagram.  Equatorial 
attachment  is  next  in  safety.  The  lower  polar  circle  is  the  boundary 
line  below  which,  according  to  Barnes,  we  have  spontaneous  placeutal 
detachment  and  unavoidable  hemorrhage,  and  above  which  spontaneous 
placental  detachment  and  hemorrhage  do  not  occur. 

COMPLICATIONS.  The  placenta  is  thinner  than  usual  and  extends 
over  a  larger  surface,  and  there  are  frequently  abnormal  adhesions  be- 
tween it  and  the  uterine  wall,  this  condition  being  found  in  nearly  one- 
third.  A  placenta  succenturiata  is  not  uncommon,  and  sometimes  the 
placenta  is  bilobed ;  the  bridge  which  connects  the  two  parts  may  be 
directly  over  the  os.  Generally  the  attachment  of  the  cord  is  mar- 
ginal ;  in  some  cases  velamentous. 

Unfavorable  presentations  are  found  in  a  large  proportion  of  cases. 
Thus  in  1148  cases  of  prsevial  placenta,  according  to  Charpentier's 
statistics,  there  were  66  per  cent,  in  which  the  head  presented,  24  per 
cent,  of  presentations  of  the  shoulder,  and  9  per  cent,  of  the  breech. 
Auvard  states  that  other  presentations  than  of  the  head  are  found  in 


1  Transactions  of  the  Brussels  Congress. 

2  Proceedings  British  Medical  Association,  1889. 


ECTOPIC  PREGNANCY. 


581 


from  20  to  nearly  50  per  cent,  of  all  cases.  Of  course,  this  anomaly 
is  in  part  to  be  attributed  to  the  fact  that  in  a  large  proportion  of  cases 
labor  is  premature. 

FIG.  169. 


DIAGRAM  ILLUSTRATING  BARNES'S  THEORY  OF  PLACENTA  PR^VIA, 

Division  of  uterus  into  zones :  A.B.  Upper  polar  circle.  C.D.  Barnes's  lower  polar  circle,  or 
Bandl's  ring.  E.F.  Circle  of  os  internum.  Ox.  Os  externum.  f.z.  Fundal  zone.  e.z.  Equatorial 
zone.  l.z.  Lower  zone.  F.Pl.  Fundal  placenta.  E.Pl.  Equatorial  placenta.  Pl.Pr.L.  Lateral  pla- 
centa praevia.  Pl.Pr.C.  Central  placenta  prsevia. 

HEMORRHAGE.  This  is  the  dominant  symptom  of  ectopic  placenta. 
The  bleeding  is  usually  sudden  and  frequently  without  obvious  excit- 
ing cause.  It  occurs  at  irregular  intervals,  and  may  disappear  almost 
as  suddenly  as  it  occurs.  Whenever  a  woman  has  such  hemorrhage  in 
the  last  two  or  three  months  of  pregnancy  and  is  not  suffering  from 
albumiuuria,  the  probability  is  the  placenta  is  previous. 

The  time  of  the  hemorrhage  is  usually,  according  to  Kaltenbach  and 
Ahlfeld  and  other  authorities,  from  seven  to  eight  mouths,  but,  as 
stated  by  Ahlfeld,  it  in  a  few  cases  is  delayed  until  the  ninth  month, 
and  more  rarely  does  not  begin  until  labor.  Depaul  held  that  almost 
all  the  hemorrhages  caused  by  p'rsevial  placenta  occurred  in  the  last  six 
weeks  of  pregnancy.  Winckel  states  that  in  partial  placenta  prsevia 
the  bleeding  generally  occurs  only  after  the  thirty-second  week,  and  in 
complete  between  the  twenty-eighth  and  thirty-sixth  week. 

THE  SOURCE  OF  THE  HEMORRHAGE.  When  the  placenta  is  par- 
tially detached  there  are  two  surfaces  with  torn  vessels,  one  placental, 
the  other  uterine;  from  which  does  the  bleeding  come?  Somewhat 
and  briefly  from  the  placental,  but  its  chief  source  is  the  uterine  sur- 
face. The  proofs  which  authorize  this  statement  are,  first,  the  hemor- 
rhage may  continue  after  labor  is  over;  second,  and  it  also  may  be  present 


382  THE  PATHOLOGY  OF  PREGNANCY. 

during  labor  when  the  foetus  is  dead ;  third,  if  a  pregnant  animal  be 
opened  so  that  the  interior  of  the  uterus  is  exposed,  and  the  placenta  be 
partially  detached,  the  blood  is  seen  to  come  from  the  uterine  surface. 
The  theory  of  the  placeutal  origin  of  the  bleeding  was  held  by  the  late 
Sir  James  Simpson.  He  said,  in  1845  :  u  I  believe  with  Dr.  Hamil- 
ton and  others  that  the  discharge  issues  principally  or  entirely  from  the 
vascular  openings  which  exist  on  that  exposed  placental  surface." 
Acting  upon  this  theory,  he  was  led  to  uphold  the  practice  of  detaching 
the  placenta  in  case  it  presented  at  the  mouth  of  the  womb,  and  became 
involved  in  a  controversy  with  Robert  Lee1  in  regard  to  both  his  theory 
and  practice ;  and  in  one  with  Radford,  who  claimed  priority  in  this 
method  for  Kinder  Wood  and  himself.  Winckel  states  the  causes  of 
hemorrhage  are  rupture  of  the  utero-placeutal  vessels,  laceration  of  a 
placental  sinus,  and  detachment  of  the  placenta  by  shocks  or  trauma, 
or  by  contractions. 

THE  CAUSES  OF  THE  DETACHMENT  OF  THE  PLACENTA.  Those 
who  hold  that  hemorrhage  prior  to  labor  is  accidental,  at  the  same  time 
state  that  the  accident  is  much  more  liable  to  occur  in  ectopic  develop- 
ment of  the  placenta  than  when  this  organ  occupies  its  normal  position, 
and  that,  as  taught  by  Rigby,  unavoidable  hemorrhage  occurs  only  in 
childbirth.  Others  explain  the  detachment  of  the  placenta  by  failure 
of  correspondence  between  its  development  and  that  of  the  uterus. 
But  while  Jacquemier2  attributed  to  the  uterus  such  rapid  development 
that  the  placenta  could  not  follow  it,  Legroux  upheld  the  opposite — that 
is,  the  placenta  is  extended  too  rapidly  with  reference  to  the  lower 
uterine  segment.  According  to  one  hypothesis,  the  uterus  grows  away 
from  the  placenta,  and  according  to  the  other  the  placenta  grows  away 
from  the  uterus.  Barnes  has  maintained  the  latter  view,  stating3 
"  that  the  first  detachment  of  the  placenta  arose  from  an  excess  of 
growth  of  the  placenta  over  that  of  the  lower  region  of  the  uterus  to 
which  it  was  attached ;  that  the  structure  of  the  uterine  region  was 
ill-fitted  to  keep  pace  with  the  placenta ;  hence  loss  of  relation,  the 
placenta  shoots  beyond  its  site,  and  hemorrhage  results."  But  Bitot* 
answers  this  theory  by  the  statement  that  at  the  time  in  pregnancy  when 
the  hemorrhages  usually  occur  the  development  of  the  placenta  has  been 
completely  accomplished  (Depaul).  Admitting  it  true,  as  claimed, 
especially  by  French  authorities,  that  the  development  of  the  fundus 
is  completed  in  the  first  seven  or  eight  months,  if  the  placenta  were 
attached  to  it  or  in  its  vicinity,  the  rapid  growth  of  the  placenta  at  the 
time  alleged  by  Barnes  would  be  in  all  cases  a  necessary  cause  of  hem- 
orrhage. 

Depaul5  has  said  that  "  it  may  be  stated  that  the  hemorrhage  consequent  upon 
vicious  insertion  of  the  placenta  results  from  this,  that  all  the  parts  of  the  uterus 
are  not  developed  in  the  same  degree,  and  while  the  fundus  and  adjoining  portions 

1  This  controversy  was  exceedingly  bitter,  especially  on  Dr.  Lee's  part.    In  one  of  his  last— ii 
not  the  last — contributions  upon  the  subject,  he  denounced  Professor  Simpson's  view  as  to  the 
source  of  the  hemorrhage  as  ••  a  gross,  unparalleled,  and  unretracted  blunder."— Lancet,  vol.  ii., 

2  Placenta  Prsevia,  by  Auvard.  a  Obstetric  Medicine  and  Surgery. 

«  Contribution  k  1'Etude  du  Mecanisme  et  du  Traitement  de  l'H£morrhagie  liee  al'Insertion 
Vicieuse  du  Placenta. 
6  Le?ons  de  Clinique  Obstetricale. 


ECTOPIC  PREGNANCY.  383 

take  at  the  beginning  of  pregnancy  a  considerable  amplitude,  and  this  during  the 
first  six  months ;  the  lower  segment  of  the  uterus,  on  the  contrary,  is  not  notably 
developed  until  in  the  last  three  months.  Moreover,  the  development  of  all  these 
regions  is  not  made  in  a  uniform  manner.  I  have  had  the  opportunity  of  exam- 
ining the  uterus  of  women  who  have  died  in  the  last  months  of  pregnancy,  and  I 
could  see  in  the  inferior  portions  that  the  increase  was  not  everywhere  the  same. 
The  anterior  region  is  generally  developed  much  more  than  the  posterior,  and  as 
I  have  said  in  a  report  which  I  presented  to  the  Academy,  if  a  vertical  line  be 
passed  downward  from  the  fundus  of  the  uterus,  its  lower  end,  far  from  passing 
through  the  cervix,  or  near  it,  would  traverse  the  anterior  wall  of  the  uterus 
at  a  variable  distance  from  the  cervix,  which  lies  posteriorly."  He  further  stated 
that  the  lateral  parts  are  developed  unequally,  the  one  increasing  more  than  the 
other,  this  disproportion  being  evident  when  a  horizontal  line  is  placed  connect- 
ing the  uterine  orifices  of  the  tubes ;  the  line  will  be  found  one  or  two  centimetres 
below  the  tube  of  the  opposite  side ;  further,  it  is  impossible  to  point  out  precisely 
either  what  part  of  the  fundus  is  developed  most,  or  when  this  increase  is  ar- 
rested. "  On  the  other  hand,  the  lower  segment  is  certainly  developed  much 
later,  but  it  is  impossible  to  assign  a  fixed  epoch  for  the  beginning  of  this  phe- 
nomenon, variable  in  each  woman,  and  we  can  only  say  that  in  general  it  com- 
mences from  the  sixth  to  the  seventh  month."  Spiegelberg,  however,  entirely 
rejected  this  view  in  explaining  the  hemorrhage.  He  maintained  that  the  bleed'- 
ing  arises  from  uterine  contractions,  causing  partial  detachment  of  the  placenta ; 
when  premature  labor1  occurs,  as  it  very  frequently  does  in  placenta  prsevia,  it 
is  not  caused  by  the  hemorrhage,  but  it  causes  the  hemorrhage. 

No  matter,  however,  the  hypothesis  accepted,  it  is  obvious  that  the 
hemorrhage  is  unavoidable. 

DIAGNOSIS.  Leopold2  asserts  that  the  course  of  the  tubes  is  a  certain 
criterion  for  the  situation  of  the  placenta.  When  the  tubes  pass  upon 
the  anterior  wall  of  the  uterus,  converging  in  their  progress,  the  placenta 
is  situated  posteriorly ;  but  if  they  pass  upon  the  lateral  borders  of  the 
uterus,  thus  nearly  parallel  with  its  long  axis,  the  placenta  is  anterior. 

Of  course,  not  finding  either  distinctive  disposition  of  the  tubes,  at 
least  the  suggestion  of  pravial  placenta  would  occur. 

Spencer3  claims  that  the  diagnosis  of  placenta  prsevia  may  be  made 
by  abdominal  palpation.  The  following  is  his  method  : 

"  The  patient  lies  upon  her  back  in  the  usual  way.  As  a  rule,  little  advantage 
is  obtained  by  drawing  up  the  knees  in  examining  by  the  abdomen  a  uterus  in 
the  later  months  of  pregnancy.  It  is  very  important  that  the  bladder  should  be 
emptied.  The  examination  is  to  be  made  between  the  pains. 

"  In  an  ordinary  vertex  presentation  (the  placenta  being  in  the  upper  segment 
of  the  uterus)  the  head  lies  almost  transversely  at  the  beginning  of  labor,  and 
the  occiput  and  'the  forehead  (at  a  higher  level)  are  to  be  easily  and  distinctly 
felt  by  the  fingers  of  the  two  hands  laid  out  flat  outside  of  the  recti  with  the 
points  downward.  Soinetimes  the  nose  is  felt,  and  I  have  felt  an  ear ;  but  the 
occiput,  the  forehead,  and  the  side  of  the  head  are  to  be  clearly  made  out  in  the 
majority  of  cases  under  favorable  circumstances. 

"  If,  however,  placenta  prsevia  be  present,  and  the  placenta  be  in  front  or  at  the 
side,  an  unusual  swelling  may  be  noted,  and  the  head  is  no  longer  felt  where  the 
placenta  is  situated ;  in  lateral  placenta  praevia  the  head  may  be  more  distinctly 
felt  on  the  oposite  side  than  in  a  normal  labor.  Where  the  placenta  is  placed  it 
feels  as  if  the  fingers  were  kept  off  the  head  by  a  mass  of  elastic  consistence  like 
that  of  a  wetted  bath-sponge ;  in  some  cases  a  distinct  edge  is  felt.  The  edge  is 
shaped  like  the  segment  of  a  circle.  Within  the  circle  all  is  obscure  to  the  touch. 

1  According  to  King's  statistics  (Transactions  of  the  State  Medical  Society  of  Indiana),  prema- 
ture labor  occurs  in  about  one-half  the  cases.    Lomer's  statistics  correspond  in  this  respect. 
-  Geburtshiilfe  und  Gynakologie,  ii.  Band,  1895. 
3  Transactions  of  the  London  Obstetrical  Society,  vol.  xxxi. 


384  THE  PATHOLOGY  OF  PREGNANCY. 

Outside  the  circle  the  head  or  other  parts  of  the  child  are  distinctly  felt.  Im- 
pulses to  the  head  are  not  distinctly  perceived  through  the  placenta,  whereas 
impulses  to  the  head  through  the  placenta  are  plainly  felt  at  the  spot  from  which 
the  placenta  is  absent ;  this  applies  also  to  the  combined  vaginal  and  abdominal 
examination.  In  doubtful  cases  it  is  important  that  several  examinations  should 
be  made,  and  it  is  constantly  to  be  borne  in  mind  that  the  placenta  always  keeps 
the  same  position.  The  examination  should  be  conducted  gently,  and  often  a 
considerable  time — several  minutes— may  be  necessary  to  satisfy  one's  self  of  the 
presence  of  the  placenta.  But  if  the  head  is  anywhere  plainly  and  distinctly 
felt,  it  may  be  safely  decided  that  the  placenta  is  not  at  that  spot.  If  a  doubtful 
spot  remains,  a  subsequent  examination  may  clear  up  the  difficulty." 

The  time  in  pregnancy  when  hemorrhage  occurs,  its  apparently  cause- 
less appearance,  abrupt  cessation,  and  frequent  recurrence  ;  the  greater 
throbbing  of  arterial  vessels  upon  vaginal  examination  with  the  finger, 
the  softened  and  relaxed  condition  of  the  lower  portion  of  the  uterus, 
and  the  inability  to  feel  distinctly  the  presenting  part  of  the  foetus  would 
render  probable  that  the  placenta  was  previous;  so,  too,  probability 
would  be  given  by  seeing  a  deeper  purplish  hue  of  the  vagina,  especially 
at  its  upper  part,  and  the  adjacent  portion  of  the  uterus.  Complete  cer- 
tainty is  had  by  passing  the  finger  into  the  cervical  canal,  and  recogniz- 
ing placental  tissue;  this  tissue  must  not  be  confounded  with  blood-clots 
and  thickened  deciclua. 

PROGNOSIS.  Ahlfeld  states  that  probably  in  general  practice  25  per 
cent,  of  women  die,  part  in  consequence  of  the  bleeding,  and  part  from 
infection  ;  Kaltenbach  believes  that  nearly  as  many  die  from  the  latter 
as  from  the  former.  Winckel  asserts  that  the  maternal  mortality  need 
not  be  greater  than  5  or  10  per  cent.,  while  the  foetal  mortality  is 
seldom  less  than  50  per  cent.,  and  in  some  statistics  is  from  70  to  75 
per  cent. 

Of  course,  the  mortality  will  depend  chiefly  upon  the  variety  of  pla- 
centa prsevia,  being  greater  in  complete  than  in  partial ;  in  some  of  the 
latter  cases,  the  lower  margin  of  the  placenta,  though  still  in  the  inferior 
uterine  segment,  being  not  near  the  os,  the  hemorrhage  may  at  no  time 
be  serious.  So  too,  the  earlier  the  abnormal  condition  is  recognized, 
and  the  prompter  and  the  more  efficient  the  means,  the  more  favorable 
the  result.  As  a  rule,  premature  labor  is  better,  so  far  as  the  chances 
of  the  mother  and  the  child  surviving. 

TREATMENT.  If  loss  of  blood  be  slight,  and  especially  if  the  foetus 
be  not  yet  viable,  the  expectant  plan  is  indicated.1  The  patient  should 
lie  down,  be  lightly  covered,  use  cold  drinks,  and  if  much  pain  or 
restlessness  be  present,  opium  may  be  given.  She  ought  to  be  directed 
not  to  take  active  exercise,  to  avoid  as  much  as  possible  the  erect  posi- 
tion, and  all  straining  at  stool.  It  would  be  well  if  there  was  some  one 
at  hand  who  was  properly  instructed  in  the  application  of  the  vaginal 
tampon,  so  that  this  may  be  at  once  used  should  grave  hemorrhage 
occur. 

1  This  advice  has  been  condemned  by  some  critics,  for  the  obstetric  knowledge  and  ability  of 
one  of  whom  I  entertain  the  greatest  respect.  I  shall  not  quote,  as  I  might,  from  Churchill, 
Depaul,  and  Spiegelberg  in  vindication,  but  simply  introduce  the  words  of  Winckel  as  one  of  the 
most  recent  and  highest  authorities,  who  in  referring  to  hemorrhage  in  pregnancy  says:  "  Should 
the  hemorrhage  be  moderate,  it  is  sufficient  for  the  patient  to  rest  in  bed."  The  objection  to 
arresting  at  once  the  pregnancy  before  the  child  is  viable  is  obvious ;  such  treatment  utterly  disre- 
gards its  life,  and  I  still  believe  should  not  be  employed  unless  the  interest  of  the  mother  impera- 
tively demands  it. 


ECTOPIC  PLACENTA.  385 

But  if  the  foetus  is  viable,  aud  the  hemorrhage  is  severe,  the  doctrine 
enunciated  by  Baudelocque  nearly  three-quarters  of  a  century  ago  ought 
to  direct  the  treatment.1  "  The  necessity  of  effecting  delivery  without 
having  regard  to  the  time  of  pregnancy,  when  the  loss  of  blood  is  so 
abundant  as  to  imperil  the  life  of  the  mother  and  that  of  the  child,  has 
been  recognized  for  more  than  two  centuries."  Admitting  this  prin- 
ciple, the  question  arises  as  to  how  the  delivery  is  to  be  effected.  The 
simplest,  shortest,  and  safest  way  is  to  induce  premature  labor,  or,  as 
nature  is  in  many  cases  endeavoring  to  do  this,  assist  her  efforts.  This 
practice  has  been  especially  advocated  by  Green halgh  aud  Thomas, 
while  many  others  have  been  following  it  without  calling  it  the  induc- 
tion of  premature  labor.  By  the  use  of  Barnes's  dilators  the  os  is 
effectively  plugged,  aud  at  the  same  time  its  rapid  expansion  secured, 
when  if  the  presentation  be  favorable,  and  the  uterine  contractions 
active,  the  membranes  may  be  ruptured  and  the  completion  of  labor 
left  to  nature. 

Doctor  D.  Draghiescu,2  Bucharest,  from  a  consideration  of  61  cases  of  placenta 
preevia,  the  maternal  mortality  being  15.08,  and  that  of  the  children  59.02  per 
cent.,  advises  if  hemorrhage  occurs  in  pregnancy,  the  loss  of  blood  not  being 
great,  expectation,  antiseptics,  rest,  and  tonics.  If  hemorrhage  recurs,  the  tam- 
pon. The  treatment  in  labor  is,  if  the  hemorrhage  is  slight,  rest  and  antiseptic 
hot-water  injections.  The  tampon  is  used  if  the  flow  is  great,  and  internal  version 
as  soon  as  practicable. 

DIFFERENT  METHODS  OF  TREATING  PLACENTA  PR^VIA.  Having 
stated  the  general  principle  which  should  govern  the  treatment  of  placenta 
prsevia,  and  the  way  in  which  this  may  be  accomplished,  it  is  proper  that 
various  methods  which  have  been  recommended  should  be  mentioned. 

THE  TAMPON.  French  obstetric  writers  have  given  to  Leroux, 
1776,  the  chief  credit  for  the  use  of  the  tampon;  nevertheless  this 
author  mentions  no  instance  of  its  application  in  placenta  prsevia.  The 
honor  of  this  application  of  the  tampon  undoubtedly  belongs  to  Wigand  ; 
by  means  of  it  he  attained  a  success  in  the  treatment  of  placenta  prsevia 
quite  equal,  if  not  superior  to,  that  of  any  other  method.  At  the  time 
he  was  led  to  make  use  of  the  tampon,  accouchement  force  was  the  gen- 
eral practice,  a  practice  which  involved  serious  dangers  and  great 
fatality.  After  many  years'  experience  with  the  tampon,  and  having 
had  a  large  obstetric  practice,  Wigand  stated  that  he  "  had  not  lost  a 
single  child  or  mother,"  and  that  he  had  secured  by  the  method  a 
normal  lying-in.3 

Different  methods  of  tamponing  the  vagina  have  been  used.  The 
rubber  bags  introduced  flaccid  in  the  vagina,  and  afterward  distended 

1  Traite  des  Accouchements. 

"  Considerations  sur  61  cas  de  placenta  prsevia.    Bucharest,  1892. 

3  Die  Geburt  des  Menschen,  etc.  The  work  was  edited  by  Franz  Carl  Naegele,  and  published  in 
1820,  three  years  after  Wigand's  death.  Notwithstanding  the  success  of  his  method,  which  he  had 
been  pursuing  for  so  many  years,  and  his  frequent  publications  concerning  it,  he  stated  that  as 
far  as  he  knew  he  had  not  "  a  single  follower." 

Wigand  employed  the  tampon  treatment  in  the  latter  part  of  the  last  century.  Nevertheless,  a 
recent  writer  has  stated  that  it  was  "  about  fifty  years  ago  ;"  but,  as  Wigand'  has  been  dead  for 
nearly  eighty  years,  of  course  this  is  a  mistake.  In  the  former  edition  I  gave  quite  fully  Wigand's 
method  of  treatment,  partly  as  a  matter  of  historical  interest,  vindicating  his  priority,  and  also  to 
show  his  remarkable  success  with  the  tampon.  Winckel  in  referring  to  my  statements  remarks  : 
"  Parvin  is  correct  in  saying  that  Wigand  should  be  credited  with  having  first  applied  the  tampon 
in  this  manner  in  placenta  prsevia  ;  and  also  in  the  statement  that  this  had  already  been  done 
toward  the  close  of  the  last  century." 

25 


386 


THE  PATHOLOGY  OF  PREGNANCY. 


with  air,  are,  in  the  opinion  of  most  obstetricians,  unreliable,  for  they 
cannot  be  perfectly  adapted  to  the  vaginal  vault,  and  thus  leave  a  space 
in  which  blood  may  collect.  Other  objections  that  have  been  made  to 
the  colpeuryuter  are  that  it  is  liable  to  tear,  and  that  it  may  be  the 
medium  of  infection.  A  tampon  can  be  made  of  balls  of  absorbent 
cotton,  each  ball  being  about  the  size  of  a  small  walnut ;  fifty  or  sixty 
of  these  will  generally  be  required — a  hatful,  according  to  Pajot.  The 
bladder  and  rectum  should  be  emptied,  the  vagina  thoroughly  cleansed 
by  an  antiseptic  solution,  and  all  clots  removed;  the  patient  may  lie 


FIG.  170. 


VAGINAL  TAMPON  IN  PLACENTA  PR.EVIA.    (After  BAILLY.) 

A.  Deeply  placed  dossils  to  each  of  which  a  cord  is  attached.    B.  Superficial  dossils  without 
cord.    C.  Pledget  of  charpie  or  pad  of  cotton.    D.  T-bandage. 

upon  her  side  or  upon  her  back,  the  latter  position  is  selected  if  Sims's 
speculum  be  used,  but  this  instrument  is  not  essential  for  perfect 
tamponing  of  the  vagina.  The  obstetrician  takes  one  of  the  cotton 
balls  after  it  has  been  dipped  in  an  antiseptic  solution,  or  covered  with 
an  antiseptic  ointment — that  of  iodoform  is  excellent — and  by  means  of 
suitable  dressing-forceps  carries  it  up  to  the  vaginal  vault ;  one  after 
another  is  thus  introduced  until  the  vault  is  completely  occupied  ;  the  os 
is  filled  or  covered  with  -the  cotton  balls,  and  after  this  the  rest  of 
the  vagina  is  perfectly  packed,  a  large  piece  of  cotton  placed  between 
the  labia,  and  the  whole  secured  by  a  napkin  and  a  T-bandage.  The 


ECTOPIC  PLACENTA.  337 

dossils  of  cotton  first  introduced  may  each  have  a  string  attached  to  them 
to  facilitate  their  removal.  The  use  of  astringent  solutions  into  which 
the  balls  are  dipped  is  unnecessary,  and  may  be  injurious  by  irritating 
the  vagina  ;  arrest  of  bleeding  by  pressure,  not  by  coagulation,  is  the 
purpose  accomplished  by  the  vaginal  tampon.  Strips  of  iodoform  or 
creolin,  or  other  antiseptic  gauze,  may  be  used  for  a  tampon. 

The  tampon  has  another  important  effect  in  the  majority  of  cases  :  it 
excites  the  action  of  the  uterus;  thus  in  78  out  of  128  cases  given  by 
Miiller,1  strong  uterine  contractions  followed  its  application. 

Winckel  states  that  he  "  employs  cotton  tampons  almost  exclusively  in  labors 
complicated  with  placenta  prsevia,  and  they  are  applied  so  firmly  that  not  a  drop 
of  blood  flows  from  the  vulva — a  condition  rarely  attained  by  the  colpeurynter 
even  when  filled  to  the  utmost.  In  central  placenta  prsevia  and  in  lateral,  tam- 
poning should  be  continued  until  the  os  is  almost  completely  dilated,  so  that  either 
the  presenting  foetal  part  may  enter  and  plug  it,  or  the  compression  of  the  placenta 
be  obtained  by  introducing  the  hand  and  bringing  down  the  breech  into  the  os. 
This  method  of  tamponing  the  vagina  in  placenta  praevia  has  recently  been  vio- 
lently assailed  and  denounced  as  unscientific  in  principle,  dangerous  in  practice, 
uncertain  in  controlling  the  hemorrhage,  and  a  prolific  source  of  septicaemia."  .  . 

"  If  the  hemorrhage  in  placenta  prsevia  springs  from  the  wall  of  the  uterus — 
whether  a  lower  uterine  segment  has  developed  or  not — AVC  must  endeavor  in 
every  case  to  compress  the  bleeding  vessels  by  as  direct  a  pressure  as  possible. 
This  purpose  is  accomplished  by  the  tampon  in  an  indirect,  not  direct,  and  at  the 
same  time  in  a  thoroughly  scientific,  manner.  The  distention  of  the  vagina  by 
the  tampons,  and  the  irritation  of  the  ganglia  in  the  upper  part  of  the  anterior 
vaginal  wall  which  they  effect,  cause  an  intense  desire  to  bear  down  and  an  in- 
creased activity  of  the  uterine  contractions.  We  increase  on  the  one  hand  the 
expulsive  force  of  the  uterus,  and  on  the  other  hand  its  power  of  resistance,  and 
last  but  not  least,  we  also  prepare  the  os  by  this  dilatation  of  the  vaginal  vault, 
and  render  it  more  yielding  in  case  any  operation  is  called  for." 

Winckel  further  states  that  he  has  never  had  a  patient  die  from  septicaemia 
consequent  upon  using  the  tampon. 

Tarnier  has  the  tampon  remain  twelve  hours ;  Depaul  did  not  re- 
move it  for  at  least  twelve  or  fifteen  hours,  or  twenty-five  to  thirty  hours 
at  most ;  it  is  doubtful  if  any  harm  will  result  should  a  properly  applied 
antiseptic  tampon  be  left  for  twenty-four  hours.  After  its  removal  the 
vagina  must  be  thoroughly  cleansed  with  an  antiseptic  solution  ;  a  new 
tampon  is  introduced  if  hemorrhage  continues,  and  if  immediate  delivery 
is  not  practicable,  unless  the  practitioner,  following  the  method  pursued 
by  Pajot  and  Bailly,  and  which  was  that  of  Wigand,  leaves  the  tampon 
in  place  to  be  expelled  by  the  uterine  and  abdominal  contractions  which 
expel  the  fnetus ;  this  plan  was  practised  and  warmly  advocated  for 
many  years  by  the  late  Dr.  Medrs,  of  Indianapolis.  Exclusive  reliance 
upon  the  tampon  in  the  treatment  of  placenta  prsevia  is  the  custom  of 
only  a  few  practitioners  ;  the  majority  of  those  who  use  it  regarding  it 
as  simply  a  temporary  means.  Miiller,2  after  observing  that  it  is  neither 
a  sovereign  remedy,  as  its  friends  claim,  nor  to  be  entirely  rejected,  as 
its  opponents  desire,  remarks  that  it  is  an  important  aid  which  should 
be  used  at  the  right  time,  and  then  no  longer  than  is  necessary  ;  apply  it 
when  the  os  is  rigid  and  only  slightly  opened,  if  violent  hemorrhage 
occurs,  for  immediate  delivery  is  impossible;  time  is  thus  gained  without 

1  Placenta  Prsevia.  2  Op.  cit. 


388  THE  PATHOLOGY  OF  PREGNANCY. 

danger,  for  even  if  it  does  not  stop,  it  lessens  the  bleeding  and  prepares 
the  parts  for  labor. 

It  has  been  objected  to  the  tampon  that  it  may  convert  an  open  into  a  con- 
cealed hemorrhage.  The  answer  is,  that  in  no  case  has  such  a  result  followed 
the  use  of  a  properly  applied  tampon.  If  during  active  labor  the  tampon  is 
forced  down  by  utero-abdominal  contraction,  and  then  when  the  contraction 
ceases  there  is  recession  of  the  uterus,  leaving  a  space  at  the  upper  surface  of  the 
tampon  in  which  blood  may  collect,  the  accident  is  prevented  by  the  practitioner 
at  once  pressing  the  tampon  back  as  soon  as  the  bearing-down  effort  ceases ;  or 
the  same  object  may  be  accomplished  by  having  the  bandage  which  secures  it 
made  of  elastic  material  which  retracts  after  having  been  stretched  during  the 
uterine  and  abdominal  contraction.  Bailly1  has  stated,  in  considering  the  treat- 
ment of  placenta  prtevia,  that  authors  are  unanimous  upon  this  point.  When- 
ever in  pregnancy  or  in  the  first  part  of  labor  a  hemorrhage,  dangerous  in  amount 
or  continuous,  occurs,  we  ought  to  tampon.  Madame  Lachapelle's  observations 
prove  that  sometimes  she  left  the  delivery  in  women  she  had  tamponed  to  Nature. 
Pajot  and  then  Weil,  taught  that  after  having  tamponed  women  suffering  with 
hemorrhages  from  placenta  prsevia  the  delivery  should  be  left  to  Nature,  this 
method  giving  the  best  results  for  the  mothers.  The  tampon  must  be  closely 
applied  to  the  os  during  a  uterine  contraction,  so  that  no  space  will  be  left  for 
the  accumulation  of  blood.  Bailly  makes  the  following  conditions  necessary  for 
the  use  of  the  tampon :  First,  there  must  not  be  uterine  inertia.  Second,  the 
tampon  must  be  properly  made  and  applied ;  the  pieces  of  charpie  should  be 
covered  with  cerate,  and  a  speculum  should  not  be  used  in  their  introduction. 
Third,  the  presentation  must  be  cranial  or  pelvic. 

According  to  the  statistics  given  by  Auvard,  when  the  tampon  was 
used  the  maternal  mortality  was  6  per  cent.,  and  the  foetal  mortality  55 
per  cent. 

ERGOT.  Auvard  states  it  as  the  method  of  Paul  Dubois.  Statistics 
show  that  the  results  of  this  treatment  are:  maternal  mortality  42  per 
cent.,  and  fetal  mortality  77  per  cent.  If  no  ergot  be  given,  the  former 
is  24  per  cent.,  and  the  latter  47  per  cent.  Auvard  adds  that  these 
figures  are  eloquent.  Ergot  given  in  these  conditions  kills  almost  one- 
half  of  the  mothers  and  more  than  one-third  of  the  children. 

COMPLETE  DETACHMENT  OF  THE  PLACENTA.  This  has  already 
been  referred  to  as  the  method  of  Simpson.2  While  the  results  as  fur- 
nished by  Simpson's  statistics  were  very  favorable  in  regard  to  maternal 
mortality,  they  showed  an  enormous  foetal  mortality ;  it  should  be  stated 
that  the  statistics  of  others  are  less  favorable  in  regard  to  maternal  mor- 
tality, and  the  method  has  now  only  a  mere  historical  interest. 

PARTIAL  DETACHMENT  OF  THE  PLACENTA.  There  are  two  varie- 
ties of  this  :  Barnes's  and  Cohen's. 

THE  METHOD  OF  BARNES.  This  is  founded  upon  the  proposition 
that  the  "  physiological  arrest  of  flooding  is  neither  permanent  nor  secure 
until  the  whole  of  that  portion  of  the  placenta  which  had  adhered  within 
the  lower  zone  of  the  uterus  is  detached — that  being  the  portion  which 
is  liable  to  be  separated  during  the  opening  of  the  lower  segment  of  the 
uterus  to  the  extent  necessary  to  give  passage  to  the  child."3  His  direc- 
tions as  to  detaching  the  portion  of  the  placenta  involved  in  this  dilata- 
tion are  as  follows:  "Pass  one  or  two  fingers  as  far  as  they  will  go 

1  Gazette  des  Hop.,  1873. 

2  Charles,  Cours  d'Accouchements.  curtly  calls  it  "  brutal  for  the  mother  and  mortal  for  the 
child." 

3  Obstetric  Operations, 


ECTOPIC  PL  A  CENT  A.  389 

through  the  os  uteri,  the  hand  being  passed  into  the  vagina,  if  necessary; 
feeling  the  placenta,  insinuate  the  finger  between  it  and  the  uterine  wall ; 
sweep  the  finger  round  in  a  circle,  so  as  to  separate  the  placenta  as  far 
as  the  finger  can  reach;  if  you  feel  the  edge  of  the  placenta  where  the 
membranes  begin,  tear  open  the  membranes  freely,  especially  if  they 
have  not  been  previously  ruptured;  ascertain,  if  you  can,  what  is  the 
presentation  of  the  child  before  withdrawing  your  hand.  Commonly, 
some  amount  of  retraction  of  the  cervix  takes  place  after  the  operation, 
and  often  the  hemorrhage  ceases.  You  have  gained  time.  You  have 
given  the  patient  the  precious  opportunity  of  rallying  from  the  shock  of 
a  previous  loss  and  of  gathering  up  strength  for  further  proceedings. 

"If  the  cervix  being  now  liberated,  under  the  pressure  of  a  firm 
binder,  ergot,  or  stimulants,  uterine  action  returns  so  as  to  drive  down 
the  head,  it  is  pretty  certain  there  will  be  no  more  hemorrhage ;  you 
may  leave  nature  to  expand  the  cervix  and  to  complete  the  delivery;  the 
labor,  freed  from  the  placeutal  complication,  has  become  natural." 
Murphy,1  pursuing  the  plan  of  partial  detachment  of  the  placenta,  as 
advised  by  Barnes,  and  dilatation  of  the  os  by  Barnes's  dilators,  in  23 
cases  saved  ten  children  and  all  the  mothers. 

COMBINED  TURNING.  In  1864  Braxton  Hicks's  well-known  volume 
upon  Combined  External  and  Internal  Version  was  published,  and  in  it 
he  advised  the  method  which  in  recent  years  has  been  so  successfully 
used,  more  especially  by  German  practitioners,  in  the  treatment  of  pla- 
centa prsevia.  Lomer7  thus  describes  it:  "Turn  by  the  bimanual 
method  as  soon  as  possible,  pull  down  the  leg,  tampon  with  it  and  with 
the  breech  of  the  child  the  ruptured  vessels  of  the  placenta.  Do  not 
extract  the  child  then,  let  it  come  itself,  or  at  least  only  assist  its  natural 
expulsion  by  gentle  and  rare  tractions.  Do  away  with  the  plug  as  much 
as  possible;  it  is  a  dangerous  thing,  for  it  favors  infection,  and  valuable 
time  is  lost  with  its  application.  Do  not  wait  in  order  to  perform  turning 
till  the  cervix  and  the  os  are  'sufficiently  dilated  to  allow  the  hand  to 
pass.'  Turn  as  soon  as  you  can  pass  one  or  two  fingers  through  the 
cervix.  It  is  unnecessary  to  'force  your  fingers  through  the  cervix'  for 
this.  Introduce  the  whole  hand  into  the  vagina,  pass  one  or  two  fingers 
through  the  cervix,  rupture  the  membranes,  and  turn  by  Braxton 
Hicks's  bimanual  method.  Use  chloroform  freely  in  performing  these 
manipulations.  If  the  placenta  is  in  your  way,  try  to  rupture  the  mem- 
branes at  its  margin ;  but  if  this  is  not  feasible,  do  not  lose  time, 
perforate  the  placenta  with  your  finger,  get  hold  of  a  leg  as  soon  as 
possible,  and  pull  it  down." 

The  following  is  a  summary  of  the  teaching  of  Braxton  Hicks.3  We  present 
it,  only  remarking  that  the  first  rule  may  be  questioned.  Is  every  case  of  preg- 
nancy with  placenta  prsevia  to  be  at  once  ended,  even  though  serious  hemorrhage 
be  absent,  and  the  foetus  not  yet  viable  ? 

1.  After  diagnosis  of  placenta  prsevia  is  made,  we  proceed  as  early  as  possible 
to  terminate  pregnancy. 

2.  When  once  we  have  commenced  to  act  we  are  to  remain  by  our  patient. 

3.  If  the  os  be  fully  expanded  and  placenta  marginal,  we  rupture  the  membranes 
and  wait  to  see  if  the  head  is  soon  pushed  by  the  pains  into  the  os. 

i  Medical  Press  and  Circular,  1885.  *  Op.  cit. 

3  British  Medical  Journal,  Nov.  30, 1889. 


390  THE  PATHOLOGY  OF  PREGNANCY. 

4.  If  there  be  any  slowness  or  hesitation,  then  we  employ  forceps  or  version. 

5.  If  the  os  be  small  and  placenta  more  or  less  over  it,  the  placenta  is  to  be 
carefully  detached  from  around  the  os ;  if  no  further  bleeding  occur,  we  may 
elect  to  wait  an  hour  or  two.     Should  the  os  not  expand,  and  if  dilating  bags 
are  at  hand,  the  os  may  be  dilated.     If  it  appear,  then,  forceps  can  be  admitted 
easily,  they  may  be  used ;  but  if  not,  version  by  combined  external  and  internal 
method  should  be  employed,  and  the  os  plugged  by  the  leg  or  breccia  of  the 
child;  after  this  is  done  the  case  may  be  left  to  nature,  with  gentle  assistance, 
as  in  footling  and  breech  cases. 

6.  If  the  os  be  small,  and  if  we  hare  neither  forceps  nor  dilating  bags,  then 
combined  version  should  be  resorted  to,  leaving  the   rest  to   nature,  gently 
assisted. 

7.  If  during  any  of  the  above  manoeuvres  sharp  bleeding  should  come,  it  is 
best  to  turn  by  combined  method  in  order  to  plug  by  breech. 

8.  When  the  foetus  is  dead,  or  labor  occurs  before  the  end  of  the  seventh 
month,  combined  external  and  internal  version  is  the  best  method,  no  force 
following. 

Iu  reference  to  the  general  subject  of  podalic  version  in  placenta 
pra3via  the  following  extract  from  Rigby  is  of  interest  :l  "  From 
what  has  been  said  it  appears,  then,  that  the  placenta  is  fixed  to  the  os 
uteri  much  more  frequently  than  has  hitherto  been  supposed ;  that 
when  it  is  so  situated,  nothing  but  turning  the  child  will  put  a  stop  to 
the  flooding." 

It  appears  that  Martin2  in  1876  made  the  definite  proposal  for  the 
treatment  of  placenta  prsevia  which  has  later  been  established  by  Behm, 
Hofmeier,  Schiilein,  and  others.  The  chief  point  in  this  treatment,  as 
proposed  by  Martin,  was  to  bring  down  the  hips  of  the  child  so  that 
their  pressure  would  stop  bleeding  from  the  partially  detached  placenta, 
and  at  the  same  time  the  activity  of  the  uterus  be  excited. 

MURPHY'S  METHOD.    This  is  fully  presented  in  the  author's  words  :3 

"  The  practice  which  I  follow  consists  not  in  a  single  method  for 
stopping  hemorrhage,  but  in  several,  and  it  is  this  :  In  the  first  place, 
in  every  one  of  my  own  patients,  or  in  those  that  I  am  consulted  about, 
when  hemorrhage  occurs  after  the  seventh  month,  when  it  is  clearly 
not  from  the  cervix  or  os,  and  when  there  is  presumptive  evidence  that 
it  is  from  the  placenta  pravia,  I  advise  premature  labor  to  be  in- 
duced ;  or  before  that  period  of  pregnancy  when  the  hemorrhage  is 
severe,  continuous,  or  frequently  recurring.  In  cases  that  permit  of  a 
little  delay  from  the  symptoms  not  being  very  urgent,  I  appoint  a  time 
when  I  can  give  a  few  hours'  continuous  attendance — two  hours  are 
generally  sufficient — as  once  you  commence  to  induce  labor  I  consider 
it  necessary  to  remain  with  the  patient  until  delivery  is  accomplished; 
and  when  the  case  does  not  require  instant  action  one  can  fix  his  own 
time  aud  can  have  what  assistance  he  requires. 

"  I  fiud  having  an  assistant  a  great  advantage,  and  by  thus  arrang- 
ing a  definite  time  practitioners  can  secure  the  services  of  a  specialist  or 
fellow-practitioner  to  help  them  and  to  share  the  responsibility.  On 
examination,  if  the  cervix  will  permit  it,  I  introduce  my  finger,  sepa- 
rate the  placenta  all  around,  and  then  put  in  a  Barnes  bag ;  and  if  not, 
I  gently  and  slowly  insinuate  my  finger  through  the  os,  which  I  have 

1  Op.  cit.  2  Lehrbuch  der  Geburtshiilfe,  von  Dr.  A.  Martin,  1891. 

3  Medical  Press  and  Circular,  1885,  p.  208. 


ECTOPIC  PLACENTA.  391 

always  found  easy  of  accomplishment,  never  having  had  recourse  to 
the  preliminary  introduction  of  a  tent,  though  in  inducing  labor  for 
other  causes  I  have  frequently  had  to  introduce  tupelo  tents.  Having 
thus  dilated  the  cervix  with  my  finger,  I  separate  the  placenta  freely 
around  the  internal  os,  and  at  once  introduce  a  Barnes  bag.  I  slowly 
fill  it  with  water — and  here  let  me  give  a  practical  hint  on  the  use  of 
hydrostatic  bags,  which  I  do.  not  remember  to  have  seen  mentioned  in 
any  of  the  text-books :  When  the  bag  is  well  through  the  cervix  it  is 
very  difficult  to  say  how  full  it  is,  and  by  continuing  the  injection  it 
may  very  easily  be  burst,  as  once  happened  to  myself,  and  has,  I  know, 
happened  to  many  others ;  so,  to  avoid  this,  it  is  desirable  to  ascertain 
and  remember  how  many  syriugefuls  each  bag  requires  before  being 
fully  dilated,  and  then  carefully  to  inject  only  that  number.  Having 
thus  filled  the  bag,  I  wait  patiently  until  the  os  is  well  dilated  around 
it,  and,  before  introducing  another  one,  separate  the  placenta  further 
should  the  hemorrhage  continue,  which  it  does  not,  provided  the  pla- 
centa has  been  sufficiently  separated  at  first.  After  the  bag  has  been 
introduced  for  some  time  the  pains  come  on  fairly  well,  though,  as  a 
rule,  they  are  not  very  strong. 

"  I  thus  proceed  until  the  os  is  fully  dilated,  when  I  give  ergot 
freely,  and  decide  what  is  the  most  suitable  course  to  follow.  If  the 
placenta  is  lateral  or  marginal,  and  the  pains  fairly  strong,  I  rupture 
the  membranes  and  leave  the  case  to  nature ;  or,  if  the  head  is  well  into 
the  pelvis,  I  may  apply  the  forceps,  but  in  the  great  majority  of  cases 
I  perform  version,  preferably  by  the  combined  method,  and  deliver  the 
child  as  quickly  as  is  consistent  with  the  safety  of  the  mother." 

Murphy  (1889)  had  S8  cases,  with  only  2  deaths;  one  of  these  was 
from  septica3mia,  and  the  second  occurred  in  a  woman  who  was  dying 
when  he  was  called  to  her.  He  believes  that  it  should  be  a  rule  to 
induce  premature  labor  in  every  case  of  placeutal  presentation  if  the 
pregnancy  has  advanced  to  seven  months,  and  even  before  this  when 
the  bleedings  are  frequent  and  serious.  Murphy's  results,  both  as  to 
maternal  and  foetal  mortality,  have  been  very  good — much  better  in 
the  latter  regard  than  those  secured  by  the  Hicks  method.  This  sus- 
tains, too,  the  position  taken  in  the  beginning  of  the  consideration  of 
the  treatment,  viz.,  the  "  induction  of  premature  labor  in  all  cases  of 
placenta  pra3via  when  the  hemorrhage  is  serious."1 

COHEN'S  METHOD.2  Two  fingers,  the  index  and  medius,  are  intro- 
duced into  the  os  and  made  to  penetrate  between  the  placenta  and  the 
uterine  wall  in  that  direction  pffering  least  resistance,  until  the  mem- 
branes are  reached  ;  the  fingers  are  hooked  over  the  border  of  the  pla- 
centa, the  membranes  ruptured,  and  the  corresponding  semicircle  of 
placental  attachment  is  broken,  and  the  placental  flap  thus  made  is 
drawn  toward  the  vagina  so  as  to  project  from  the  mouth  of  the  womb. 

RUPTURE  OF  THE  MEMBRANES.  The  method  is  generally  known 
as  that  of  Puzos.  This  obstetrician,  in  1759,  described  his  treatment 
of  placenta  prsevia  as  consisting  in  dilatation  of  the  os  with  his  finger, 

1  The  writer  advocated  this  treatment  several  years  ago.    American  Practitioner,  1875, 1876. 

2  Dr.  Davis,  of  Wilkesbarre,  Pa.,  without  knowing  Dr.  Cohen's  practice,  was  led  to  adopt  a 
similar  practice,  and  has  been  quite  successful  with  it. 


392  THE  PATHOLOGY  OF  PREGNANCY. 

and  then  rupture  of  the  membranes.  According  to  Auvard,  the  results 
of  the  method  of  Puzos  at  the  Clinique  d'Accouchements  and  the  Ma- 
ternite  were  a  maternal  mortality  of  13  per  cent,  and  a  foetal  mortality 
of  46  per  cent. 

Rupture  of  the  membranes  is  not  in  all  cases  followed  by  arrest  of 
the  hemorrhage.  Thus  in  Miiller's  statistics  it  is  shown  that  while 
bleeding  ceased  in  six  cases,  in  five  others  it  continued  or  increased. 
There  must  be  active  uterine  contractions  to  secure  hsemostasis  ;  if  these 
are  not  present,  or  do  not  follow  the  discharge  of  the  amuial  liquor,  the 
patient's  danger  is  increased  by  this  treatment. 

The  practitioner  will  act  wisely  who  adapts  his  treatment  to  the  con- 
ditions of  the  case;  it  may  be  necessary  to  use  the  tampon,  temporarily 
at  least,  in  one  case,  to  use  dilators  in  another,  to  perform  podalic  ver- 
sion in  a  third,  to  apply  forceps  in  a  fourth,  simply  to  rupture  the 
membranes  in  a  fifth,  or  to  give  ergot,  or  to  combine  two  or  more  of  the 
various  methods,  all  these  when  so  used  being  but  means  to  one  end — 
delivery. 

Among  other;  methods  of  treating  placenta  prsevia  may  be  mentioned 
that  proposed  by  Dr.  "W.  H.  Ford,1  of  St.  Louis.  This  is  the  perform- 
ance of  Csesarean  section ;  he  limits  the  application  of  this  treatment  to 
the  graver  forms  of  abnormal  implantation  of  the  placenta. 

In  1894  Bernays,2  of  St.  Louis,  did  this  operation  successfully  in  a 
case  of  central  placenta  prsevia ;  the  mother  made  a  favorable  conva- 
lescence, but  the  child  died  a  few  hours  after  delivery. 

Hemorrhage  occurring  after  delivery,  a  by  no  means  rare  sequel  in 
cases  of  placental  pravia,  will  be  considered  in  the  treatment  of  post- 
partum  hemorrhage. 

PREMATURE  DETACHMENT  IN  NORMAL  IMPLANTATION  OF  THE 
PLACENTA.  Dangerous  hemorrhage  may  result  in  the  latter  part  of 
pregnancy,  or  in  labor,  from  premature  detachment  of  the  placenta  when 
this  organ  occupies  its  normal  situation  in  the  uterus.  The  hemorrhage 
may  be  either  open  or  concealed.  The  following  history  of  a  case  of 
the  former  variety  which  occurred  during  my  term  of  service  at  the 
Philadelphia  Hospital  has  been  furnished  me  by  the  resident  physician, 
Dr.  John  Chalmers  Da  Costa,  under  whose  charge  she  was  : 

J.  L.,  thirty  years  of  age,  multigravida,  when  at  the  end  of  the  seventh  month 
of  pregnancy,  slipped  and  fell,  the  right  iliac  region  striking  a  boiler.  She  im- 
mediately had  severe  pain,  and  blood  flowed  from  the  uterus  to  the  amount  of 
nearly  a  quart  in  a  few  minutes,  then  stopped.  The  finger  readily  entered  the 
external  and  then  the  internal  os.  The  pulse  was  rapid  and  very  weak ;  the 
expression  anxious ;  body  agitated  with  tremors  and  covered  with  cold  sweat ; 
pupils  dilated ;  heart's  action  weak,  irregular,  and  beats  intermittent ;  respiration 
shallow  and  hurried.  Immediately  upon  being  placed  in  bed  she  was  given 
whiskey  and  aromatic  spirit  of  ammonia ;  the  head  of  the  bed  was  lowered  by 
raising  the  foot ;  the  vagina  was  washed  out  with  a  hot  solution  of  corrosive  sub- 
limate, and  opium  given  freely.  The  hemorrhage  did  not  return,  and  the  pain 
gradually  subsided  in  two  days  The  pregnancy  went  to  term,  when  she  was 
delivered  of  a  healthy,  well-developed  child. 

This  history  shows  that  a  grave  uterine  hemorrhage  does  not  neces- 
sarily arrest  the  pregnancy.  It  also  shows  that  traumatism  may  be  an 

1  American  Gynecological  Journal,  September.  1892. 

2  Journal  of  the  American  Medical  Association,  May,  1894. 


ECTOPIC  PLACENTA.  393 

important  cause  of  accidental  hemorrhage.  It  may  also  occur  from 
acute  infectious  diseases,  as  variola,  scarlatina,  and  acute  yellow  atrophy 
of  the  liver.  Lifting  a  heavy  weight,  severe  vomiting,  abnormal  short- 
ness of  the  cord,  violent  coughing,  and  straining  at  stool  have  been  given 
as  causes.  But  the  most  frequent  cause  is  disease  of  the  placenta ;  in 
rare  instances  haemophilia  has  been  the  cause. 

In  some  instances  the  cause  of  the  premature  detachment  of  the  pla- 
centa was  the  usual  contractions  of  the  uterus  in  pregnancy.  But.  as 
suggested  by  Kaltenbach,  in  such  cases  there  must  be  assumed  some 
change  in  the  inner  portion  of  the  serotina,  rendering  its  vessels  unusu- 
ally brittle  and  readily  torn.  Winter  and  Fehliug  have  found  a  con- 
nection between  nephritis  and  premature  separation  of  the  placenta;  the 
latter  regards  the  more  frequent  occurrence  of  white  fibriuous  iufarcts  of 
the  placenta  in  nephritis  as  the  cause  of  premature  detachment.  Von 
Weiss1  describes  a  small-celled  infiltration  of  the  endometrium,  with  pecu- 
liar changes  of  the  decidual  cells ;  he  saw  a  typical  case  of  numerous 
fresh  infarcts  in  premature  placental  separation.  Veit  maintains  that 
we  cannot  admit  nephritis  as  a  cause  of  the  accident  without  the  medium 
of  endometritis. 

The  hemorrhage  may  be  internal  or  external.  In  the  former  case  the 
blood  effused  is  included  between  the  detached  placenta,  or  that  part  of 
it  which  is  separated,  in  cases  of  incomplete  separation,  and  the  mem- 
branes on  the  one  side  and  the  uterine  wall  on  the  other.  In  some 
cases  the  placenta  may  be  completely  detached  except  at  its  border,  and 
a  great  mass  of  blood,  a  retro-placental  clot,  cause  it  to  project  in  the 
uterine  cavity.  As  a  rule  the  bleeding,  though  internal  for  a  time,  be- 
comes also  external,  and  then  any  doubt  as  to  the  nature  of  the  accident, 
which  may  have  quite  suddenly  brought  the  patient  in  a  condition  of 
alarming  prostration,  with  severe  pain  at  some  part  of  the  uterus,  and 
the  sensation  of  terrible  distention  of  this  organ,  is  gone. 

The  prognosis  is  more  favorable  in  external  than  in  internal  bleeding. 
Labor  generally  comes  on  if  the  hemorrhage  occurs  in  pregnancy. 
Almost  without  exception  the  children  perish,  and  a  very  large  per- 
centage of  the  mothers,  though  possibly  the  statistics  of  the  late  Dr. 
Goodell  present  too  dark  a  prognosis  in  regard  to  maternal  mortality. 
Graefe 2  has  reported  twelve  cases,  only  ten  of  the  mothers  dying,  and  the 
statistics  of  Galabin  certainly  are  much  less  unfavorable  than  those  of 
Goodell. 

Goodell  advised  early  rupture  of  the  membranes,  immediately  fol- 
lowed by  the  application  of  a  very  tight  binder  and  compresses  to  the 
abdomen,  ergot  freely,  and  prompt  delivery  by  forceps  or  version.  The 
Csesarean  section  has  been  proposed  as  securing  a  prompter  emptying 
the  uterus  than  can  be  had  by  other  means. 

Budin3  believes  that  expectation  is  the  better  course  before  labor  so 
long  as  the  woman's  life  does  not  seem  to  be  compromised. 

The  mortality  of  the  mothers  in  the  cases  collected  by  Goodell4  was 
nearly  51  per  cent,  and  that  of  the  children  94  per  cent.  Galabin 

1  Ueber  vorzeitige  L6sung  der  normal  sitzeenden  Nachgeburt.    Vienna,  1893. 

*  Zeitschr.  f.  Geburts.  und  Gynakol.,  Bd.  xxiii. 

8  Le<;ons  de  Clinique  Obstetricale. 

4  American  Journal  of  Obstetrics,  vol.  ii. 


394  THE  PATHOLOGY  OF  PREGNANCY. 

states1  that  out  of  23,591  deliveries  in  the  Guy's  Hospital  Lyiug-in 
Charity  there  were  31  cases  of  accidental  hemorrhage,  as  compared  with 
41  of  placenta  pnevia ;  21  only  were  serious,  and  of  these  there  were  5 
deaths  of  mothers  from  hemorrhage,  while  the  foetal  mortality  was  66 
per  cent. 

TREATMENT.  In  the  less  severe  forms  of  accidental  hemorrhage  active 
interference  is  not  indicated.  The  reader  will  find  several  cases  of  acci- 
dental hemorrhage  recorded  by  Rigby 2  in  which  immediate  delivery  was 
not  attempted ;  indeed,  he  insisted  upon  the  different  treatment  to  be 
pursued  in  case  of  accidental  hemorrhage  from  that  required  when  the 
placenta  was  at  the  mouth  of  the  womb,  in  the  latter  urging  the  impor- 
tance of  immediate  delivery.  The  patient  will  lie  with  her  head  low, 
her  body  lightly  covered,  and  stimulants  be  administered  as  required  ; 
the  tampon  is  used  if  there  is  external  hemorrhage.  In  grave  internal 
hemorrhage,  however,  most  obstetricians  from  Baudelocque  on  to  the 
present,  including  such  names  as  Goodell,  Schroder,  and  Barnes,  have 
taught  that  the  membranes  should  be  ruptured,  and  the  uterus  promptly 
emptied. 

But  rupture  of  the  membranes  must  not  be  done  before  the  os  is  dilated  ; 
this  dilatation  may  be  made  by  Barnes's  dilators,  or  in  some  cases  by  the 
fingers.  Graefe  advises,  in  case  dilatation  cannot  be  readily  made  in  the 
unshortened  cervix,  the  performance  of  the  Csesarean  operation. 

As  illustrating  the  greater  danger,  if  the  bleeding  is  internal,  of  seven 
cases  recently  reported  by  Despres,  Jardiue,  Maygrier,  and  Suter,  death 
occurred  in  three,  and  in  two  of  the  three  the  hemorrhage  was  internal. 
(Neugebauer.) 

The  danger  is  not  always  over  though  the  uterus  is  emptied.  Grapow,3 
in  a  case  of  internal  hemorrhage,  delivered  the  patient  with  forceps,  and 
after  the  delivery  a  large  mass  of  clots  was  expelled,  the  uterus  was 
tamponed,  and  the  patient  died,  though  no  fresh  hemorrhage  occurred 
after  the  introduction  of  the  tampon.  So,  too,  a  similar  case  from 
Schauta's4  clinic  is  given,  delivery  being  by  podalic  version  of  a  recently 
dead,  large  child  ;  the  completely  detached  placenta  followed  the  extrac- 
tion of  the  child  ;  the  uterus  was  thoroughly  tamponed  with  iodoform 
gauze,  which  arrested  hemorrhage,  but  in  two  hours  the  woman  was  dead. 

1  Op.  cit.  3  Op.  cit. 

s  Centralblatt  f.  GynSkol.,  1892.  «  Ibid,  1893. 


CHAPTEE   II. 

DISEASES     THAT    ARE     EXAGGERATIONS     OF     PHYSIOLOGICAL    CONDI- 
TIONS   OF,    OR   OTHERWISE    DEPENDENT    UPON,    PREGNANCY. 

HYPEREMESIS  :  obstinate,  iucoercible,  uncontrollable,  pernicious 
vomiting  of  pregnancy.  The1  common  occurrence  of  some  gastric  dis- 
turbance in  the  earlier  months  of  pregnancy  has  been  mentioned,  and 
also  the  hygienic  and  medical  treatment  of  the  less  severe  cases  of  the 
disorder  given.  We  are  now  concerned  with  the  exaggeration  of  this 
affection,  an  exaggeration  which  in  some  cases  may  be  so  great  that  not 
only  the  pregnancy  but  the  life  of  the  woman  is  imperilled. 

In  about  two-thirds  of  the  cases  of  hyperemesis  of  pregnancy  the 
disease  begins  before  the  end  of  the  third  month.  In  most  patients 
there  is  at  first  a  gradual  passing  of  the  ordinary  nausea  and  vomiting 
into  the  severe  form  of  the  disorder,  and  the  patient's  stomach  rejects 
the  simplest  food,  liquid  or  solid,  in  a  short  time  after  it  is  received.  It 
may  be  you  see  her  take  even  only  ice-water,  but  with  eagerness  and  relish, 
and  you  congratulate  her  upon  retaining  it,  but  her  previous  experience 
leads  her  to  reply  :  "No  ;  it  will  come  up  as  soon  as  it  gets  warm,"  and 
the  event  in  a  short  time  verifies  the  prediction.  There  may  be  copious 
secretion  of  saliva  associated  with  the  emesis,  and  the  dribbling  discharge 
annoys  the  patient  night  and  day.  Change  of  position,  as  from  the  back 
to  the  side,  or  the  reverse,  will  often  be  the  exciting  cause  of  vomiting. 
The  tongue  becomes  dry,  the  gums  spongy  and  bleeding,  the  breath  offen- 
sive, the  thirst  immoderate,  and  the  urine  scanty  and  high-colored ;  the 
pulse  is  90  to  100,  or  even  more  frequent.  The  inability  to  retain  food, 
and  the  loss  of  rest,  for  even  the  night  gives  no  intermission  to,  scarcely 
remission  of,  the  vomiting,  and  the  distressing  nausea,  result  in  a  rapid 
emaciation  and  loss  of  strength  ;  the  patient,  necessarily  confined  to  her 
bed,  may  faint  upon  attempting  to  stand,  or  even  upon  sitting  up ;  her 
face  is  sharp,  haggard,  sometimes  of  a  dusky  hue,  or  oftener  remarkably 
pale;  her  eyes  sunken,  the  skin  frequently  cold  and  clammy ;  prostrate, 
and  almost  utterly  hopeless,  she  may  be  willing  or  eager,  as  relief  from 
her  prolonged  and  severe  suffering,  to  welcome  death,  whose  shadow 
seems  to  be  resting  upon  her. 

In  the  above  sketch,  an  endeavor  has  been  made  to  represent  the 
condition  of  a  patient  under  my  care  several  years  since.  She  was  in  her 
third  pregnancy ;  the  two  previous  ones — I  was  not  then  her  physician 
— had  been  ended  by  artificial  abortion,  though  the  symptoms,  according 
to  her  own  and  her  husband's  statement,  were  not  so  grave  as  now 
presented.  Her  condition  was  so  serious  that  an  able  and  estimable 

1  According  to  the  statistics  of  Giles,  London  Obstetrical  Society's  Transactions,  vol.  xxxv., 
"one-third  of  pregnant  women  are  free  from  sickness  throughout  pregnancy." 


396  PATHOLOGY  OF  PREGNANCY. 

practitioner  who  saw  her  iu  consultation  with  me  thought  that  the 
induction  of  abortion  furnished  the  only  hope,  and  probably  this  had 
been  delayed  too  long.  Nevertheless  the  patient  recovered.  The  vom- 
iting gradually  ceased  in  the  sixth  month,  and  at  the  end  of  the  normal 
period  she  gave  birth  to  a  healthy,  well-developed  male  child. 

But  the  result  is  not  in  all  cases  so  fortunate.  Diarrhoea  may  occur, 
and  hence  the  emaciation  and  exhaustion  are  more  rapid  and  extreme. 
The  patient  passes  into  the  second  stage  of  the  disease,  in  which  the 
grave  symptoms  previously  given  become  graver;  "there  are  slight 
manifestations  of  fever ;"  in  some  there  is  acute  paiu  in  the  head,  in  the 
epigastrium,  or  in  one  or  the  other  hypochondrium ;  "the  emaciation  is 
frightful,  and  attacks  of  syncope  are  frequent."  The  third  stage  suc- 
ceeds. Vomiting  usually  ceases,  but  in  some  cases  continues,  blood 
being  mixed  with  the  vomited  matters  ;  jaundice  occurs  ;  not  alone  the 
breath,  but  the  body  emits  an  unpleasant  odor;  the  pulse  is  from  120 
to  140,  and  is  small  and  thread-like;  mental  disorder  is  shown  in  hal- 
lucinations and  delirium,  and  coma  closes  the  scene. 

The  duration  of  the  disease  is  in  most  cases  from  two  to  three  months. 
Of  the  118  cases  collected  by  Gueiiiot,  46  died.  In  the  third  stage  a 
fatal  result  is  almost  inevitable.  The  disease  is,  in  some  instances,  com- 
plicated1 with  pulmonary  tuberculosis,  intestinal  catarrh,  or  round  gastric 
ulcer.  In  some  cases  spontaneous  abortion  occurs,  and  if  the  patient  be 
not  too  exhausted,  convalescence  follows.  The  vomiting  dependent  upon 
the  pregnancy  should  not  be  confounded  with  that  which  may  be  caused 
by  albuminuria,  cancer  of  the  stomach,  or  tuberculous  meningitis ;  these 
mistakes  have  been  made. 

The  older  authors,  says  Jaffe',2  gave  a  mortality  of  44  per  cent. 
Horwitz  had  13  cases,  5  of  them  fatal;  Joulin  collected  121  cases, 
death  occurring  in  49. 

CAUSES.3 — The  etiology  of  the  vomiting  of  pregnancy,  whether  this 
vomiting  be  mild  or  severe,  is  obscure.  Various  theories  have  been 
proposed.  That  which  has  been  generally  received  is,  that  the  gastric 
disorder  is  sympathetic  ;4  that  is,  it  is  caused  by  sympathy  between  the 
uterus  and  stomach.  We  now  substitute  reflex  for  sympathetic,  but 
thereby  add  nothing  to  our  knowledge  in  explaining  the  phenomenon. 
Violent  vomiting  is  also  observed  when  the  pregnant  uterus  is  subject 
to  severe  internal  pressure,  or  in  plural  pregnancies,  or  in  polyhydram- 
uios  ;  or  when  the  organ  has  become  incarcerated  in  the  pelvis.  Hewitt 
has  dwelt  especially  upon  versions  and  flexions  of  the  uterus  as  causes. 
Bennet  asserts  an  important  connection  between  inflammation  of  the 
neck  of  the  womb  and  the  vomiting  of  pregnancy ;  circumscribed  in- 

1  Kormann.  2  Jaffe  :  Ueber  Hyperemesis  gravidarum. 

8  One  of  the  curious  facts  in  regard  to  the  dangerous  vomiting  of  pregnancy  is  its  comparatively 
rare  occurrence  among  the  Germans.  Kaltenbach,  indeed,  has  gone  so  far  as  to  deny  the  propriety 
of  artificial  abortion  in  the  treatment,  saying  that  if  there  be  disease  of  the  stomach,  as  cancer  or 
ulcer,  the  vomiting:  continues  after  the  uterus  is  emptied  ;  and  if  the  vomiting  have  a  nervous 
origin,  it  is  amenable  to  an  appropriate  causal  or  psychical  treatment  without  interrupting  the 
pregnancy. 

4  The  term  sympathetic  can  be  more  appropriately  applied  to  the  nausea  and  vomiting  of  the 
husband  as  a  consequence  of  his  wife  being  present,  and  thus  suffering.  Seeing  another  vomit, 
especially  if  there  be  a  strong  attachment  for  the  one  thus  affected,  and  especially,  too,  if  the  vom- 
iting be  very  frequent,  may  cause  vomiting.  Possibly,  too,  there  is  something  to  be  attributed  to 
unconscious  imitation  in  marital  vomiting.  Certainly  the  few  facts  illustrating  this  disorder  in 
the  husband  are  not  to  be  regarded  as  wonderful  and  mysterious,  but  admit  of  a  very  simple 
explanation. 


HYPEREMESIS.  397 

flammation  of  the  body  of  the  womb  is  a  cause,  according  to  others ; 
rigidity  of  the  tissues  of  the  cervix,  or  adhesion  of  the  membranes  at 
the  internal  os,  are  causes  given  by  still  others.  While  the  influence 
of  at  least  some  of  these  will  be  admitted  in  individual  cases,  there 
are  cases  in  which  none  of  them  is  present.  According  to  Lebert  and 
Rosenthal,  in  some  cases  the  nausea  and  vomiting  are  nervous,  partial 
manifestations  of  a  general  nerve  inanition  ;  and  Barnes  refers  to  the 
stomach  as  not  the  seat  of  the  disease,1  but  "  simply  that  of  election  for 
the  discharge  of  superfluous  nervous  energy;"  but  these  are  merely  un- 
proved hypotheses. 

Giles,  op.  cit.,  "  regards  vomiting  as  chiefly  one  mode  of  manifestation  of  nerv- 
ous instability,  and  so  dependent  on  the  interaction  of  three  main  factors : 

"1.  The  increased  nervous  irritability  of  pregnancy. 

"2.  A  local  source  of  irritation. 

"  3.  A  ready  efferent  channel  for  nervous  energy  (the  vagi)." 

Vinay,  in  considering  the  etiology,  includes  lesions  of  the  uterus,  lesions  of  the 
stomach,  and  the  state  of  the  nervous  system.  He  maintains  that  the  real  cause 
of  obstinate  vomiting  is  the  pathological  condition  of  the  nervous  system,  that  is, 
a  functional  neurosis  characterized  by  an  abnormal  excitability  of  the  reflexes, 
and  which  is  probably  of  hysteric  nature. 

Certainly,  many  of  the  cases  have  hysterical  manifestations,  often  preceding 
the  vomiting,  the  latter  replacing  them,  and  many  of  the  reported  cures  have 
been  by  such  utterly  trivial  means  that  they  could  only  have  acted  suggestively, 
and  others  by  some  profound  mental  impression. 

TREATMENT.  This  is  dietetic,  medical  and  surgical,  and  obstetric. 
When  the  vomiting  is  not  very  severe,  a  trial  of  various  different  arti- 
cles of  food  may  be  made,  as  previously  suggested,  with  the  hope  that 
some  one  of  them  may  be  acceptable  to  the  stomach ;  but  if  it  be  severe, 
it  is  better,  as  so  strongly  urged  by  Dr.  Busey,  not  to  allow  the  patient 
to  take  anything,  not  even  a  lump  of  ice,  by  the  mouth,  the  stomach 
being  given  absolute  rest.  Rectal  alimentation  should  be  the  chief  trust. 
The  late  Dr.  Austin  Flint  has  recorded2  the  case  of  a  patient  who  lived 
sixteen  months  solely  by  this  means.  The  late  Dr.  Henry  F.  Campbell 
thus  successfully3  treated  a  lady  for  the  vomiting  of  pregnancy,  continuing 
the  method  for  fifty-two  days ;  so  sanguine  was  he  of  its  applicability  and 
value  that  he  stated  "  under  the  careful  and  systematic  application  of 
rectal  alimentation,  artificial  abortion  for  the  relief  of  gravid  nausea 
can  be  banished  from  practice,  even  as  a  last  resort."  Dr.  Busey  ad- 
vises enemata  of  beef-tea,  bromide  of  potassium,  tincture  of  opium,  and 
brandy  every  four  hours  during  the  first  twenty-four  or  forty-eight 
hours,  and  afterward  at  longer  Intervals.  At  the  end  of  forty-eight 
hours  he  begins  nourishment  by  the  stomach,  using  milk  and  lime-water. 

Animal  broths,  peptonized  milk,  the  whites  of  eggs  stirred  in  water, 
Leube's  pancreatic  meat  emulsion,  and  defibrinated  blood  may  also  be 
used  for  injections  into  the  rectum. 

Unfortunately  in  some  of  the  cases  of  grave  vomiting  there  is  already 
diarrhoea,  and  the  rectum  is  intolerant  of  even  so  small  a  quantity  as 
just  advised ;  or  again,  in  other  cases  after  these  injections  have  been 

1  Op.  cit.  2  American  Practitioner,  1878. 

3  Transactions  of  the  American  Gynecological  Society,  vol.  iii. 


398  PATHOLOGY  OF  PREGNANCY. 

successfully  used  for  several  days,  such  rectal  intolerance  may  result 
that  this  method  of  nourishment  must  be  abandoned. 

Blundell  suggested  "injecting  blood  into  the  vessels  in  case  of  a  high  degree 
of  weakness  and  irritability  of  the  stomach  and  bowels  "  He  referred,  in  sup- 
port of  this  proposed  method,  to  an  experiment  he  had  made  upon  a  dog,  into 
whose  jugular  vein  he  injected  every  day,  or  every  other  day,  for  three  weeks, 
several  ounces  of  blood ;  the  dog  was  allowed  water  only,  and  at  the  end  of  the 
time  was  in  good  condition. 

MEDICAL  AND  SURGICAL  TREATMENT.  The  chief  medical  and  sur- 
gical means  have  been  mentioned.  In  all  cases  of  persistent  and  severe 
vomiting  a  vaginal  examination  must  be  made,  and  where  possible, 
means  at  once  used  to  correct  any  uterine  displacement  that  may  be 
present.  Alkalies,  autispasmodics,  laxatives,  or  stimulants  may  find 
useful  application.  By  some  practitioners  more  reliauce  is  placed  upon 
opium,  or  morphine,  than  upon  other  agents.  Matthews  Duncan  com- 
mends atropine ;  Talma,  of  Utrecht,  has  recommended  nitro-glyceriu, 
one  milligramme  in  the  course  of  the  day,  given  in  three  doses ;  Bailly 
succeeded  in  relieving  an  obstinate  case  of  vomiting  in  pregnancy,  by 
applying  to  the  dorso-lumbar  region  Chapman's  rubber  bag  filled  with 
ice-water,  and  a  blister  to  the  epigastrium.  Cohnstein1  regards  the 
preparations  of  bromine  as  especially  useful  in  the  vomiting  of  the  early, 
not  of  the  late,  mouths ;  if  it  is  not  suitable  for  the  case,  the  first  doses 
fail  to  relieve,  and  it  should  not  be  continued.  Menthol  and  orexin  are 
among  recent  remedies  advised ;  the  latter  proved  in  one  of  my  patients 
without  the  least  value. 

Washing  out  the  stomach  has  in  some  cases  been  beneficial,  and  in 
others  giving  food  through  a  stomach-tube.  Ahlfeld  refers  to  a  case  near 
the  end  of  pregnancy  in  which  the  vomiting  depended  upon  excessive 
uterine  distentiou,  that  was  relieved  by  puncture  of  the  membranes. 

Kohler  has  cured  a  case  of  obstinate  hysterical  vomiting,  by  pencil- 
ling the  fauces  with  a  10  per  cent,  solution  of  muriate  of  cocaine;  the 
same  method  might  be  tried  with  a  fair  prospect  of  occasional  success 
in  cases  of  pregnancy  vomiting. 

OBSTETRIC  TREATMENT.  As  these  patients  generally  recover,  pro- 
vided the  exhaustion  be  not  too  great  when  the  womb  is  emptied,  the 
induction  of  abortion  or  of  premature  labor  may  be  necessary.  The 
proportion  of  recoveries  after  one  or  the  other  event  is  given  by  Gu6- 
niot  as  two-thirds ;  and  among,  those  who  die  the  death  of  some  is  to 
be  attributed  to  delay  in  the  operation.  The  induction  of  premature 
labor  in  a  case  of  hyperemesis  that  persists  in  spite  of  the  best  treat- 
ment, and  imperils  life,  need  not  cause  the  least  hesitation  on  the  part 
of  the  practitioner.  But  the  question  of  abortion  is  a  graver  one ;  it  is 
the  certain  sacrifice  of  one  life,  and,  unless  absolutely  demanded  for  the 
saving  of  the  mother's  life,  is  murder.  No  man  should  take  so  serious 
a  responsibility  as  causing  abortion  in  a  case  of  hyperemesis  unless  in- 
dorsed in  his  action  by  a  qualified,  conscientious  consultant.  But  at 
the  same  time  he  should  remember  the  words  of  Pajot :  "  The  true, 

i  Cent.  f.  Gynak.,  1891. 


RELAXATION  OF  THE  PELVIC  JOINTS  399 

radical  treatment  of  incoercible  vomiting  in  pregnancy  is  emptying  the 
uterus." ' 

RELAXATION  OF  THE  PELVIC  JOINTS.  Swelling  and  softening  of 
the  pubic  and  sacro-iliac  joints  occur  normally  in  pregnancy ;  exagger- 
ation of  this  condition  allowing  decided  motion  is  a  pathological  condi- 
tion. The  pubic  is  more  frequently  affected  than  either  of  the  sacro- 
iliac  joints;  the  disorder  usually  occurs  in  the  latter  half  of  pregnancy, 
generally  in  the  last  two  months,  but  Moreau  has  mentioned  a  case  in 
which  the  condition  began  in  the  second  month  ;  in  this  patient  the 
relaxation  continued  for  more  than  two  years  after  delivery.  Having 
once  occurred,  it  may  reappear  in  successive  pregnancies.  The  late 
Professor  Meigs  stated  that  one  of  his  patients,  who  had  been  confined 
twelve  times,  generally  suffered  for  several  weeks,  in  the  latter  part 
of  each  pregnancy,  from  relaxation  of  the  pubic  joints.  On  the 
other  hand,  one  of  my  patients  who  in  the  latter  part  of  her  first  preg- 
nancy suffered  from  relaxation  of  the  pubic  and  of  the  left  sacro-iliac 
joints,  and  for  nearly  a  year  after  delivery  was  not  able  to  walk, 
passed  through  her  second  pregnancy  without  any  manifestation  of  the 
disorder. 

Relaxation  of  the  pelvic  joints,  first  described  by  Hippocrates,  begins 
gradually ;  there  is  a  feeling  of  weakness  or  weariness,  especially  after 
walking ;  this  after  a  time  is  followed  by  pain  upon  exertion,  but,  after 
rest,  ceases.  The  pain  may  be  distinctly  referred  to  the  joint  affected, 
especially  if  that  be  the  pubic,  and  pressure  upon  it  by  the  finger  shows 
increased  sensibility.  The  patient  will  protest  against  exercise,  unwisely 
advised  under  these  circumstances  ;  she  will  say  it  causes  severe  distress 
near  the  hips,  that  her  steps  are  uncertain,  and  she  feels  as  if  there  was 
something  "giving  way"  in  the  pelvic  bones.  When  she  walks  her 
steps  are  waddling.  Barker2  states  that  the  patient  can  stand  with 
comparative  ease,  resting  upon  one  leg  or  the  other,  but  cannot  balance 
herself  upon  both  legs  at  once.  Abnormal  movement  in  the  pubic 
joint  can  readily  be  detected  by  placing  two  fingers  upon  the  posterior 
surface  of  the  joint  when  the  patient  is  standing,  and  then  having  her 
move  the  lower  limbs  alternately ;  in  some  cases  it  may  be  recognized 
when  the  patient  is  lying  in  bed.  Very  frequently  there  are  pain  and 
numbness  in  the  lower  limbs.  The  joint  may  become  very  sensitive,  so 
that  the  slightest  movement  in  bed  involving  the  pelvis  is  attended 
with  severe  suffering,  and  the  unhappy  patient  is  condemned  to  absolute 
repose.  The  relaxation  having  once  begun  increases  until  pregnancy 
ends.  In  some  cases  labor,  either  natural  or  artificial,  may  cause  rup- 
ture, or,  either  in  pregnancy  or  in  the  lying-in,  inflammation  of  the 
joint  may  occur.  Each  of  these  events,  however,  is  very  rare.  A 
guarded  prognosis  should  be  given,  for  while  recovery  is  the  rule,  it  is 
in  some  cases  very  slow,  and  in  few  rapid. 

TREATMENT.  Rest  is  of  the  first  importance  when  this  affection 
occurs  in  pregnancy.  I  am  quite  sure  one  of  my  patients  was  injured 
by  persistent  efforts  to  walk  in  the  last  weeks  of  pregnancy.  A  pro- 
longed rest,  too,  is  necessary  after  labor,  and  when  the  patient  gets  up 

1  Arch,  de  Tocol.,  Oct.  1889.  2  Puerperal  Diseases. 


400  PATHOLOGY  OF  PREGNANCY. 

the  joints  should  be  immobilized  by  a  suitable  apparatus.  Barker  states 
that  in  all  cases  he  has  seen,  this  immobilization  has  been  effected  by  a 
little  ingenuity  in  making  and  adapting  a  hip-binder  of  very  strong, 
coarse  cloth.  Boyer  recommended  a  girdle  of  leather.  Snelling1  has 
suggested  sole-leather,  properly  moulded  to  the  shape.  Martin's  girdle, 
according  to  Bailly,  has  in  several  instances  immediately  corrected  ab- 
normal mobility  of  the  pelvic  joints,  and  enabled  the  patient  at  once  to 
stand  and  to  walk.  A  plaster- of- Paris  bandage  would  probably  be 
as  efficient  and  more  economical. 

INFLAMMATION  OF  THE  PELVIC  JOINTS.  This  has  sometimes 
occurred  in  pregnancy,  but  oftener  after  labor ;  it  may  follow  relax- 
ation, or  occur  without  it.  The  inflammation  usually  affects  but  a 
single  joint.  In  very  rare  cases  suppuration  occurs ;  thus,  Kiwisch 
evacuated  half  a  pint  of  thick  pus  from  the  pubic  joint.  Hilton  has 
narrated  a  case2  in  which  inflammation  of  the  sacro-iliac  joint  followed 
labor ;  the  inflammation  ended  in  suppuration,  but  the  pus  was  ab- 
sorbed. 

RUPTURE  OF  THE  PELVIC  JOINTS.  This  is  a  rare  accident;  it 
usually  affects  the  pubic  joint,  but  may  also  one  or  both  sacro-iliac 
joints.  It  is  impossible  for  it  to  occur  in  natural  delivery  or  in  ordi- 
nary obstetric  operations  unless  there  be  an  anterior  lesion.  The  treat- 
ment is  rest  and  a  firm  hip-bandage. 

HYDR^EMIA.  By  this  is  meant  an  increase  in  the  serous  portion  of 
the  blood.  Associated  with  it  the  red  corpuscles  are  lessened  and  the 
proportion  of  white  is  greater.  Stoltz3  describes  the  condition  as  a 
serous  cachexia,  "  a  cachexia  which  does  not  differ  from  symptomatic 
dropsy,  for  example,  that  which  results  from  organic  disease  of  the 
heart,  in  its  course  and  in  its  ordinary  termination.  Instead  of  being 
connected  with  a  local  organic  malady,  it  is  the  consequence  of  a  vicious 
composition  of  the  blood,  an  exaggerated  hydrsernia." 

There  may  be  oedema  of  the  lower  limbs  only,  or  it  may  become  gen- 
eral, and  there  may  be,  in  addition  to  serous  effusion  in  the  connective 
tissue,  effusion  also  into  the  great  serous  cavities,  especially  in  that  of 
the  abdomen.  The  face  is  puffed,  the  limbs  swelled,  the  external  geni- 
tal organs  much  distended,  clear,  almost  transparent,  looking  like  sacs 
of  water.  The  patient  is  incapable  of  exercise  from  her  lower  limbs 
being  so  swelled,  and  moreover  she  is  exhausted  by  slight  exertion ; 
there  are  palpitation  of  the  heart  and  difficult  breathing.  In  some  cases 
the  foetus  dies  and  premature  labor  or  miscarriage  occurs.  The  urine 
is  abundant  and  contains  no  albumin,  or  only  a  trace  of  it ;  and  there- 
fore the  condition  is  not  to  be  confounded  with  the  oedema  which  may 
occur  in  renal  disease. 

In  some  cases  the  effusion  into  the  connective  tissue  is  so  great  that 
gangrenous  patches  may  be  formed  upon  the  lower  limbs  or  upon  the 
external  organs  of  generation. 

TREATMENT.  While  we  endeavor  to  improve  the  nutrition  of  the 
patient  by  suitable  diet  and  the  administration  of  tonics,  especially  of 

1  American  Journal  of  Obstetrics,  vol.  ii. 

2  Pain  and  the  Therapeutic  Influence  of  Rest. 

*  Nouveau  Dictionnafre  de  Mfidecine  et  de  Chirurgie  Pratiques,  tome  vii. 


ANAEMIA.  401 

iron,  and  employ  occasional  derivation  to  the  intestinal  canal,  or  excite 
increased  activity  of  the  kidneys,  the  most  immediately  beneficial  result 
is  obtained  by  the  use  of  hot  baths.  In  using  the  hot  bath  the  tem- 
perature of  the  water  should  be  98°  to  100°  F. ;  the  patient  remains  in 
the  bath  for  twenty  minutes,  and  during  this  time  drinks  half  a  pint  of 
hot  water  ;  immediately  after  coming  out  of  the  bath  the  skin  is  quickly 
and  well  dried,  and  she  is  wrapped  in  a  warm  blanket  and  remains  in  a 
warm  room,  a  copious  perspiration  lasting  an  hour  or  more  is  caused, 
and  the  relief  is  great  and  immediate.  (Edema  of  the  lower  limbs  is 
treated  by  rest  in  the  recumbent  position,  or,  when  sitting  up,  placing 
the  limbs  upon  a  chair ;  that  of  the  vulva  requires  frequent  cold  bath- 
ing, possibly  in  some  cases  a  compress  and  bandage ;  in  either  manifes- 
tation of  the  disease  punctures  may  be  necessary  to  prevent  gangrene. 
In  ascites  the  effusion  may  be  so  great  that  it  either  must  be  removed 
or  the  pregnancy  ended  ;  Cohnstein1  gives  very  decided  preference  to  the 
former,  and  certainly  this  is  the  wiser  choice.  If  there  be  serous  effu- 
sion into  the  thorax,  so  that  there  is  great  interference  with  respiration, 
thoracentesis  should  be  done  without  hesitation,  as  this  operation  is  well 
borne  by  pregnant  women.  Punctures  of  the  labiae  may  be  required 
when  the  oadema  is  very  great ;  but,  of  course,  careful  antisepsis  must  be 
observed  in  such  operation. 

ANAEMIA — PERNICIOUS  ANAEMIA.  In  the  affection  which  has  just 
been  considered  there  is  that  which  is  designated  as  anaemia.  But  there 
may  be  such  anemia  without  the  grave  manifestations  that  have  been 
described  ;  for  example,  the  oedema  if  present  is  only  slight.  In  addi- 
tion to  the  discomforts  of  the  condition,  it  carries  with  it  future  dangers, 
especially  that  of  post-partum  hemorrhage.  Hence  the  importance  of 
improving  the  character  of  the  blood  by  proper  diet,  by  correcting  any 
digestive  disorder  that  may  be  present,  and  especially  by  giving  an  iron 
tonic ;  the  prophylactic  treatment  of  some  cases  of  post-partum  hemor- 
rhage ought  to  begin  in  pregnancy. 

Pernicious  anasmia  is  a  much  rarer  and  graver  disease.  In  1858,  Dr. 
Barclay2  published  the  report  of  a  case  of  anemia,  the  disorder  occur- 
ring in  the  puerperal  state,  and  proving  fatal  the  fifth  month  after  de- 
livery. Addison,  in  1855,3  described  a  grave  form  of  anaemia,  which 
he  termed  idiopathic.  Lebert,  in  1853,  recorded  cases  of  fatal  puerperal 
chlorosis  at  Zurich,  where  subsequent  observations  were  made  by  Gus- 
serow  and  Biermer ;  he  regarded  them  as  examples  of  essential  anaemia. 
Biermer,  in  1871,4  published  an  account  of  15  cases  of  what  he  termed 
progressive  pernicious  anaemia;  and  Gusserow  five  cases  of  this  disease 
in  pregnant  women.  Coupland3*  collected  110  cases,  54  of  the  subjects 
being  females,  and  in  20  of  these  the  starting-point  of  the  pernicious 
anaemia  was  pregnancy. 

CAUSES  AND  SYMPTOMS.  Malaria,  insufficient  or  improper  food, 
multiparity,  obstinate  vomiting,  hemorrhage,  violent  emotion,  mental 
shock,  and  diarrhoea  are  among  the  alleged  causes  in  some  cases.  In 
other  cases  no  explanation  of  the  occurrence  of  the  malady  could  be 

1  Op.  cit.  2  Medical  Times,  1851. 

3  Sydenham  Society's  edition  of  Addison's  Works,  p.  212. 

4  Ziemssen's  Cyclopaedia,  vol.  xvi.  6  Gulstonian  Lectures,  1881. 

26 


402  THE  PATHOLOGY  OF  PREGNANCY. 

given.  lu  the  majority  of  cases  the  disease  begins  gradually.  The 
face  grows  more  and  more  pale  and  presents  a  waxy  appearance;  in 
some  cases  it  is  slightly  yellow,  but  it  is  not  emaciated,  the  patient  re- 
taining, for  a  time  at  least,  her  general  plumpness  of  form,  for,  as 
Addison  remarked,  there  may  be  an  actual  increase  in  subcutaneous  fat. 
After  a  time  fever  occurs,  and  then  there  may  be  some  emaciation.  The 
more  prominent  general  symptoms  are  palpitation  of  the  heart,  fainting, 
headache,  generally  sleeplessness,  but  in  some  drowsiness;  hemorrhages 
are  not  unusual ;  there  may  be  epistaxis  or  bleeding  from  swelled  and 
spongy  gums,  the  appearance  being  that  of  scorbutus ;  cerebral  hemor- 
rhage has  been  occasionally  observed,  and  cases  of  retinal  hemorrhage 
have  been  frequent.  Though  Charpentier  states  the  latter  are  rare, 
Quincke,  quoted  by  Coupland,1  found  such  hemorrhage  in  all  but  7  of 
31  cases ;  Sorensen2  found  it  in  10  cases  out  of  11  examined.  The 
urine  is  abundant,  contains  no  albumin,  or  only  a  trace,  has  a  low 
specific  gravity,  and  is  light-colored.  Fever,  called  by  Biermer  anaemic 
fever,  is  a  striking  characteristic  of  the  disease.  The  blood  shows  great 
deficiency  in  haemoglobin,  and  in  case  this  constituent  be  lessened  to 
about  one-fifth  the  normal  quantity,  the  disease,  according  to  Quin- 
quaud,3  invariably  has  a  fatal  result.  Not  only  is  the  quantity  of  red 
corpuscles  lowered,  but  here  and  there  micrococci  moving  about  rapidly 
are  found  in  the  blood.4 

TREATMENT.  Good  food  and  tonics,  especially  iron,  are  of  first  im- 
portance. Inhalation  of  oxygen  has  been  tried.  Transfusion  has  been 
tried  several  times,  but  has  rarely  been  beneficial ;  in  one  case  the  num- 
ber of  red  globules  was  less  forty-eight  hours  after  than  it  was  before 
the  operation.  Interruption  of  pregnancy,  proposed  by  Gusserow,  and 
approved  by  Charpentier,  is  condemned  by  Kleinwachter  as  hastening 
the  usual  fatal  termination  of  the  disease. 

In  the  autumn  of  1856,  and  in  the  succeeding  winter  and  spring,  there  occurred 
in  Indianapolis,  at  that  time  my  home,  and  its  vicinity  several  cases  of  what 
physicians  then  termed  puerperal  anaemia,  but  which  has  since  been  described 
by  Gusserow  and  others  as  pernicious  anaamia ;  this  conclusion,  I  think,  will  be 
drawn  by  any  one  who  reads  the  appended  description  of  the  disease  and  com- 
pares it  with  that  previously  given.  Dr.  Funkhouser,5  who  treated  several  of 
these  cases,  read  a  paper  before  a  local  society,  giving  a  narrative  of  them. 
Having  myself  seen  two  patients  suffering  with  puerperal  anaemia,  and  having 
heard  the  doctor's  paper  read,  I  hoped  to  have  at  least  the  leading  facts  contained 
in  it  to  present  in  this  work.  But  unfortunately  he  failed  to  find  the  paper,  and 
in  lieu  of  it  sent  me  the  following  note : 

"  Having  been  requested  to  furnish  you  with  a  paper  upon  puerperal  anemia, 
which  I  read  before  the  Indianapolis  Medical  Society  in  1857,  and  the  paper 
having  been  mislaid,  I  will  endeavor  to  give  from  memory  the  chief  facts  it  con- 
tained There  were  probably  in  the  city  about  twenty  cases  in  all  of  the  disease, 
and  all,  or  nearly  all,  proved  fatal  during  gestation,  in  labor,  or  shortly  after. 
It  seemed  to  me  that  the  disease  manifested  three  forms,  (1)  purely  anaemic,  (2) 
scorbutic,  and  (3)  cachectic.  In  all  there  was  hemorrhage  from  some  mucous 
surface,  in  the  scorbutic  from  the  gums.  There  was  total  anorexia;  the  patient 
suffered  from  neuralgic  pains,  they  were  pallid,  exsanguineous,  in  some  cases  had 

1  Op.  cit.  2  Archives  Generates  de  Medecine,  tome  I.,  1880. 

a  Ibid.,  1879.  «  Winckel. 

5  The  late  Dr.  Funkhouser  was  an  esteemed  practitioner  of  Indianapolis  for  nearly  forty  years  ; 
he  was  graduated  at  Jefferson  Medical  College  in  1847.  He  died  July,  1886. 


VARICOSE  VEINS.  403 

a  jaundiced  hue,  and  the  skin  had  here  and  there  purplish  spots.  Generally 
there  was  irritability  of  the  stomach,  but  the  most  striking  feature  was  an  utter 
aversion  to  food.  Some  of  the  patients  had  suffered  with  malarial  fever,  but  in 
many  there  was  no  such  history.  In  many  cases  premature  labor  occurred,  and 
it  was  not  uncommon  for  the  foetus  to  be  dead,  both  in  such  labor  and  in  labor 
at  term." 

I  have  merely  to  add  to  this  note  that  the  disease  was  chronic,  having  no  cor- 
respondence in  this  respect  with  acute  yellow  atrophy  of  the  liver,  and  that  t 
can  recall  only  two  cases  in  which  the  patients  recovered,  and  in  each  instance 
the  recovery  occupied  several  months. 

VARICOSE  VEINS.  The  proportion  of  women  who  in  pregnancy 
have  varicose  veins,  as  has  been  mentioned,  Budin  states  to  be  twenty 
to  thirty  per  cent.,  but  Caziu1  makes  the  number  one  in  twenty-one. 
The  latter  proportion,  I  think,  from  observations  made  at  the  Philadel- 
phia Hospital,  nearer  correct.  Varicose  veins  are  found  with  almost 
relatively  equal  number  in  primigravidae  and  in  multigravidse,  though 
less  distinct  in  the  former ;  in  the  one  they  appear  from  the  fourth  to 
the  fifth  month,  but  in  the  others  from  the  second  to  the  third.  The 
internal  sapheua  is  in  most  cases  first  affected,  and  in  some  it  only  is 
concerned,  but  the  external  saphena  is  frequently  secondarily  involved. 
Varicose  veins  in  the  majority  of  cases  are  found  ouly  in  the  lower 
limbs,  quite  as  often  in  the  left  as  in  the  right;  in  some  cases  the  disease 
exists  also  in  the  external  genital  organs,  and  in  a  few  affects  them  alone. 

Among  the  causes  of  varicose  veins  in  pregnancy  the  following  have 
been  alleged  :  Gravitation,  compression  of  intra-abdominal  veins  by  the 
uterus,  increase  of  blood,  change  in  its  character,  and  increased  vascular 
tension. 

Cazin  refers  to  the  case  of  a  cook,  quoted  by  Chaussier,  who  always  knew  her- 
self to  be  pregnant  by  the  development  of  varices  in  her  lower  limbs ;  this  mani- 
festation occurred  in  the  second  month.  By  compressing  them  she  readily 
produced  abortion.  Cazin  suggests  from  this  incident  that  the  enlarged  veins 
act  as  a  diverticulum  for  the  blood  plethora,  which  not  thus  provided  for  would 
affect  the  womb  and  end  the  pregnancy. 

Varicose  veins  may  cause  oedema.  It  results  from  the  internal  pres- 
sure of  the  blood  being  greater  than  the  external  pressure  upon  the 
vessels.  Pregnancy  predisposes  to  eczema,  and  this  tendency  is  assisted 
by  the  patient's  scratching  the  limbs  to  relieve  the  itching  with  which 
a  varicose  part  is  often  affected.  The  scratching  may  lead  to  the  forma- 
tion of  a  varicose  ulcer,  though  this  is  not  frequent,  it  having  been 
observed  but  once  in  forty-seven  cases  of  varicose  veins  in  pregnancy. 
The  treatment  of  the  eczema,  usually  eczema  simplex,  and  of  varicose 
ulcer,  are  the  same  as  in  the  non-pregnant  condition. 

The  most  serious  complication  of  varicose  veins  is  rupture.  If  it  be 
external,  an  open  hemorrhage  results ;  but  if  internal,  and  the  skin  un- 
broken, the  effused  blood  forms  a  tumor  commonly  known  as  a  thrombus. 
A  thrombus  of  the  lower  limbs  is  rare,  but  one  of  the  external  genital 
organs  comparatively  frequent ;  the  latter  may  occur  before,  during,  or 
after  labor ;  the  last  form  is  most  frequent.  Bryant2  has  reported  a 
case  in  which  a  spontaneous  subcutaneous  rupture  of  the  internal 

1  Archives  de  Tocologie,  1880-1.  2  Medical  Times  and  Gazette,  1850. 


404  THE  PATHOLOGY  OF  PREGNANCY. 

sapheua  occurred  in  a  pregnant  woman,  with  the  formation  of  a  throm- 
bus on  the  inner  side  of  the  thigh.  Cazin  met  with  a  similar  case,  only 
the  rupture  was  not  spontaneous,  but  caused  by  violence.  The  treat- 
ment of  thrombus  is  rest,  with  cold  applications  to  the  swelling.  The 
effused  blood  is  usually  absorbed,  but  in  occasional  instances  suppura- 
tion occurs.  Rupture  of  a  varicose  vein  with  external  hemorrhage  has 
occurred  from  straining  at  stool,  from  lifting  a  heavy  weight,  standing 
for  a  long  time,  or  a  prolonged  walk,  and  by  a  fall  or  a  blow,  or  from 
scratching  a  varicose  ulcer.  In  some  cases,  however,  the  rupture  has 
been  without  obvious  cause :  for  example,  when  the  patient  was  in  bed 
and  asleep.  If  the  opening  be  from  a  large  vessel  and  the  bleeding  be 
not  promptly  arrested,  death  comes  very  quickly.  Several  fatal  cases 
have  been  reported.  It  should  be  remembered,  in  explanation  of  the 
rapidly  mortal  results,  that  the  blood  comes  not  only  from  the  distal, 
but  also  from  the  cardiac  side  of  the  opening  in  the  vein. 

A  pregnant  woman  who  has  varicose  veins  ought  to  avoid  all  those 
causes  which  may  lead  to  rupture,  such  as  being  costive,  carrying  heavy 
loads,  standing  long,  etc.  She  should  lie  down  a  part  of  each  day,  and, 
if  the  veins  are  very  much  enlarged,  she  may  wear  a  flannel  bandage 
when  up.  She  should  further  be  advised  as  to  the  best  means  of  arrest- 
ing the  flow,  i.  e.,  immediate  and  firm  pressure  upon  the  bleeding  point. 
The  professional  attendant  called  to  a  case  of  hemorrhage  from  the  rup- 
ture of  a  varicose  vein  of  one  of  the  lower  limbs  will  in  most  cases 
succeed  in  permanently  stopping  the  bleeding  by  the  application  of  a 
compress  and  bandage.  Should  this  treatment  fail,  a  needle  is  passed 
into  the  skin  on  one  side  of,  then  beneath,  the  bleeding  vessel,  and  finally 
through  the  skin  on  the  other  side;  a  figure-of-8  ligature  is  firmly  ap- 
plied to  the  projecting  ends  of  the  needle ;  Cazin  suggests  a  serrefine  if 
the  opening  be  small. 

PREGNANCY-KIDNEY.  Albuminuria  in  a  pregnant  woman  is  not 
uncommon.  In  a  few  cases  it  may  be  the  manifestation  of  a  chronic 
nephritis  that  was  present  previously  to  the  gestation,  or  it  may  be  from 
an  accidental  acute  nephritis.  But  the  majority  of  pregnant  albumi- 
nurics  become  so  because  of  the  pregnancy  itself. 

Various  explanations  of  the  occurrence  of  this  fact  have  been  offered. 
The  pregnancy-kidney,  the  Schwangerschaftmiere  of  Leyden,  has  been 
by  some  supposed  to  originate  from  increased  intra-abdominal  pressure, 
from  stasis  in  the  renal  veins,  either  from  spasm  of  arteries  (Cohnheim), 
or  from  pressure  upon  the  ureters  (Halbertsma) ;  Leyden  denied  the 
existence  of  inflammation,  but  regarded  anemia  of  the  kidney,  with 
oedematous  swelling,  and  fatty  degeneration  of  the  epithelium,  chiefly 
of  the  glomeruli,  as  characteristic  (Runge).  Kaltenbach  has  suggested 
that  very  probably  the  irritated  condition  of  the  kidneys  is  caused  by 
pathological  metabolic  products  from  the  ovum  or  from  the  maternal 
organism  (toxalbumin). 

Albuminuria  and  dropsy  are  characteristic  of  the  disease,  which  is 
usually  not  manifested  until  the  second  half  of  pregnancy,  and,  as  a 
rule,  disappears  after  the  pregnancy  is  over.  The  urinary  deposit  shows 
cylinders,  lymph  corpuscles,  a  few  red  corpuscles,  and  fatty  degen- 
erated renal  epithelium. 


TREATMENT  OF  ALBUMINURIA  IN  PREGNANCY.  4Q5 

Pregnancy  nephritis  is  more  frequent  in  primigravidse,  and  more  fre- 
quent, too,  if  the  uterus  contains  more  than  one  foetus. 

The  prognosis  is  not  unfavorable.  For  example,1  in  the  Charite,  Ber- 
lin, in  1888-89  there  were  1587  deliveries,  and  of  the  women  .ten  had 
pregnancy-kidney,  but  none  of  the  ten  had  eclampsia. 

Sometimes,  however,  one  affected  with  the  disease  may  suffer  from 
sudden  lessening  of  the  urine  and  increase  of  albumin,  and  eclampsia 
be  threatened. 

Eclampsia  occurs  more  frequently  in  consequence  of  acute  than  of 
chronic  nephritis.  Severe  renal  disease  in  pregnancy  is  dangerous  to  the 
foetus,  the  danger  arising  partly  from  premature  detachment  of  the  pla- 
centa, but  chiefly  the  foetal  death  is  caused  by  so-called  white  infarcts 
of  the  placenta.  Colm,  quoted  by  Runge,  found  84  per  cent,  of  chil- 
dren of  mothers  suffering  with  renal  disease  born  macerated  or  non- 
viable. 

TREATMENT  OP  ALBUMINURIA  IN  PREGNANCY.  The  most  im- 
portant part  of  the  treatment  in  milder  cases  is  a  milk2  diet.  In  graver 
cases  there  may  be  conjoined  hot  baths,  abundant  perspiration  being 
secured  by  the  patient  remaining  in  a  warm  room  after  coming  out  of 
the  bath,  and  drinking  freely  hot  water  or  hot  milk.  Wiuckel  has  for 
more  than  twenty  years  directed  for  pregnant  women  having  notable 
albuminuria,  every  morning  one  or  more  pills,  each  containing  three- 
fourths  of  a  grain  of  extract  of  aloes,  and  of  extract  of  colocynth. 
Lohlein  has  the  patient  lying  in  bed  to  be  in  the  abdomi no-lateral 
position.  Borak  and  Bernheim,  in  order  to  stimulate3  diuresis  in  severe 
cases,  have  used  subcutaneous  infusion  of  the  so-called  normal  salt  solu- 
tion ;  the  injection  of  the  solution  is  made  in  the  nates  or  abdominal 
wall,  and  500  to  1000  grammes  may  be  injected  at  one  time.  Their 
results  have  been  good.  The  question  as  to  the  interruption  of  the 
pregnancy  in  some  cases  of  albumiuuria  will  be  considered  hereafter. 

1  Cent.  f.  GynSkol.,  1891. 

2  The  value  of  the  milk  diet  has  been  claimed  by  Rivi6re,  op.  cit.,  to  depend  especially  upon  the 
fact  that  this  food  leaves  the  least  possible  residue  for  intestinal  putrefaction,  such  putrefaction  of 
ordinary  food  leading  to  the  formation  of  new  toxic  principles  which,  entering  the  blood,  are  im- 
portant factors  in  the  production  of  eclampsia. 

3  Nouv.  Arch.  d'Obstet.  et  de  Gyn.,  1893. 


CHAPTER    III. 

ECLAMPSIA. 

ECLAMPSIA  —  PUERPERAL  ECLAMPSIA  —  PUERPERAL  CONVUL- 
SIONS. Eclampsia  is  an  acute  disease  occurring  in  women  in  pregnancy, 
in  labor,  or  in  childbed,  often  sudden  in  its  onset,  rapid  in  its  progress, 
characterized  by  convulsions,  with  loss  of  sensation  and  of  conscious- 
ness, ending  in  coma.  (Bailly.)  The  sudden  onset  is  indicated  by  the 
word  eclampsia,  from  £K?.dinru,  to  shine  out,  to  flash. 

The  intimate  connection  in  most  cases  between  this  disease  and  albu- 
minuria  suggests  that  its  consideration  should  immediately  follow  that 
of  the  latter.  It  belongs  to  the  pathology  of  pregnancy  rather  than  to 
that  of  labor,  for  though,  according  to  most  authorities,  it  is  more  frequent 
in  the  latter  than  in  the  former,  it  is  more  serious  if  it  occurs  in  pregnancy. 
Possibly,  too,  as  held  by  Bailly,1  it  is  really  more  frequent  in  pregnancy, 
for  as  labor  generally  results  from  eclampsia,  many  of  the  cases  of  the 
disease  may  have  been  reported  as  occurring  in  labor,  and  "  statistics 
often  fail  in  giving  information  as  to  whether  labor  had  actually  begun 
before  the  first  convulsion."  The  disease  is  most  frequent  in  the  last 
months  of  pregnancy,  though  it  has  been  observed  as  early  as  the  first 
month.  Considering  eclampsia  as  it  may  occur  in  pregnancy,  in  labor, 
or  in  childbed,  its  frequency,  according  to  Kleinwachter2  and  Galabin,3 
is  one  in  500 ;  Kormaun  makes  the  proportion  one  in  600,  Cazeaux 
one  in  200.  Corson4  met  with  10  in  3036  cases  of  labor — that  is, 
about  1  in  300.  One  can  approximate  the  number  of  cases  of  eclamp- 
sia by  ascertaining  the  number  that  died  from  this  disease  and  multi- 
plying it  by  four,  for  in  general  it  may  be  stated  that  not  more  than 
25  per  cent,  of  puerperal  eclamptics  recover.  Studying  the  vital  statis- 
tics of  Philadelphia  for  this  end,  and  in  the  way  mentioned,  it  will  be 
found  that  in  1890  there  were  27,858  births,  56  cases  of  eclampsia; 
1891,  29,764  births,  136  cases  of  eclampsia;  and  in  1892,  29,826 
births  and  60  cases  of  eclampsia.  Using  the  several  numbers  of 
eclamptic  cases,  each  as  a  divisor  of  the  number  of  births,  supposed  to 
be  equivalent  to  labors  of  the  same  year,  we  get  the  results — 1  eclamptic 
to  495  labors  in  1890,  1  to  233  in  1891,  and  1  to  498  in  1892. 

While  we  have  thus  an  approximate  estimate  of  the  proportion  of 
cases  of  eclampsia  to  labors,  we  have  also  shown  that  the  frequency  of 
eclampsia  varies  in  different  years. 

Bidder  has  recorded5  455  cases  of  eclampsia  occurring  from  1873  to 
1891  in  the  St.  Petersburg  Maternity,  the  proportion  of  eclamptic  cases 
being  1  in  123  births. 

1  Kouveau  Dictionnaire  de  Medecine  et  de  Chirurgie  Pratiques,  tome  xii. 

2  Op.  cit.  3  Op.  cit. 

*  New  York  Medical  Journal,  May,  1886.  6  Arch.  f.  Gynakol.,  Band  xliv. 


ECLAMPSIA.  407 

PREMONITORY  SYMPTOMS.  These  occur  in  almost  all  cases.  The 
m  )st  important  are  headache,  disturbance  of  vision,  and  epigastric  pain.1 
The  first  is  generally  in  the  forehead,  and  in  some  upon  one  or  upon 
the  other  side  of  the  forehead  ;  it  is  rarely  in  the  occiput.  Hamilton 
referred  to  frontal  pain  as  especially  characteristic.  At  first  it  is  not 
continuous,  but  has  irregular  intermissions,  or  at  least  remissions  ;  when 
it  becomes  constant  the  attack  is  at  hand.  It  is  the  most  frequently 
manifested  premonitory  symptom.  It  is  not  unusual,  if  this  pain  occur 
several  days  before  the  convulsive  manifestations,  for  slight  mental  dis- 
order to  be  associated  with  it,  generally  simply  dulness  of  intellect  or 
apathy ;  the  patient,  too,  may  be  either  sleepless  or  drowsy.  Disturb- 
ance of  vision  is  observed  in  very  many  cases.  This  at  first  is  usually 
indistinctness  of  sight  or  inability  to  use  the  eyes  for  more  than  a  few 
minutes  at  a  time ;  the  letters  on  the  page  which  the  patient  is  reading 
are  blurred,  or  she  cannot  take  the  stitches  in  the  work  she  is  sewing 
in  the  right  place;  she  wearies  in  the  effort  and  lays  aside  one  or  the 
other  object.  In  rare  cases  more  or  less  complete  blindness  may  be 
present  for  hours,  or  even  for  days  before  the  attack  ;  in  other  instances 
amblyopia,  hemiopia,  or  diplopia  is  manifested.  Epigastric  pain  is  the 
least  frequent  of  the  prodromata.  If  present,  it  may  be  so  severe  that 
the  patient  groans,  or  even  criep  out  with  the  suffering ;  she  leans  for- 
ward to  relax  the  abdominal  muscles,  and  usually  has,  with  the  pain, 
oppression  or  difficulty  in  breathing.2  Other  premonitory  symptoms 
have  been  observed  in  some  cases,  such  as  vertigo,  vomiting,  ringing 
in  the  ears,  irritability  of  temper,  and  despondency. 

Ahlfeld  gives  among  the  more  important  prodromal  symptoms,  anuria,  albu- 
minuria,  oedema  of  the  lower  limbs,  of  the  genitals,  of  the  skin  of  the  trunk,  of 
the  upper  limbs,  and  of  the  face,  especially  of  the  eyelids,  slight  twitching  of 
the  muscles  of  the  face,  and  slight  opisthotorios,  and  weakness  of  memory. 

THE  ATTACK.  After  a  longer  or  shorter  duration  of  some  of  the 
prodromata — their  apparent  absence  in  any  case  probably  being  from 
a  failure  of  observation — the  convulsive  manifestations  come  abruptly. 
The  patient  lying  in  bed  may  have  been  talking  to  you  one  minute ; 
the  next  she  is  silent,  and  you  see  her  face  in  complete  repose,  her  eyes 
fixed  apparently  upon  some  distant  object  and  her  body  motionless ; 
this  is  the  brief  calm  which  precedes  the  terrible  storm.  While  you 
are  looking,  and  possibly,  if  it  is  your  first  experience,  wondering  why 
her  speech  has  so  suddenly  ceased,  the  storm  begins  with  quick  move- 
ments of  the  eyelids  and  of  the  nasal  alse,  then  of  all  the  muscles  of  the 
face.  The  eyelids  rapidly  open  and  close,  the  pupils  are  dilated  and 
insensible  to  light,  the  eyeballs  move  in  various  directions,  then  are  half 
hidden  beneath  the  upper  lids,  the  face  turns  slowly  toward  one  and 

1  This  was  mentioned  among  the  premonitory  symptoms  of  eclampsia  in  the  former  editions.    A 
few  years  since  there  appeared  in  one  of  the  London  medical  journals  several  communications 
upon  this  symptom,  some  writers  apparently  thinking  it  was  a  recent  discovery,  and  others  re- 
ferred to  the  neglect  to  mention  it  in  works  upon  obstetrics.    Such  criticism  could  only  have  been 
made  by  those  whose  obstetric  reading  was  very  limited  or  very  careless.    For  example,  Rams- 
botham  mentioned  this  symptom,  and  so  did  Jacquemier,  1846,  and  Chailly-Honore,  1842,  and  be- 
fore these  Denman.    Ramsbotham's  words  are  "  severe  cramps  in  the  stomach."    Velpeau,  1835, 
states,  in  referring  to  premonitory  symptoms.  "  Denman  and  others  have  attached  great  importance 
to  pain  in  the  stomach." 

2  Auvard  gives  as  the  principal  prodromata  disturbance  of  vision,  epigastric  pain,  the  conse- 
quence of  dyspnoea,  and  dyspnoea  the  result  of  imperfect  action  of  the  lungs. 


408  THE  PATHOLOGY  OF  PREGNANCY. 

then  to  the  other  shoulder,  the  mouth  is  distorted,  usually  deviated  to 
the  left.  The  wave  of  convulsion  extends  to  the  muscles  of  the  trunk 
and  limbs,  and  a  stage  of  tonic  contraction  occurs;  the  body  is  rigid 
and  the  back  is  arched  as  from  opisthotonos ;  the  lower  and  upper  limbs 
are  rigid  and  usually  extended ;  the  thumb  is  flexed  upon  the  palm,  and 
the  fingers  contracted  over  it.  Bailly  mentions  a  case  in  which  at  the 
beginning  of  numerous  convulsive  attacks  the  unhappy  patient  invari- 
ably raised  the  left  arm  over  her  face,  almost  in  the  position  taken  to 
ward  off  a  threatened  blow  ;  and  in  one  of  Olshauseu's.  patients,  calling 
the  name  of  her  husband  immediately  preceded  the  seizure.  The  dia- 
phragm and  thoracic  muscles  are  involved  and  respiration  is  arrested ; 
the  livid  pallor  of  the  face  is  succeeded  by  a  dusky  red  hue ;  the  face  is 
swelled  and  indicates  asphyxia ;  the  muscles  at  the  base  of  the  tongue 
cause  this  organ  to  protrude  from  the  half-open  mouth,  and  it  is  in 
many  cases  more  or  less  severely  bitten,  and  then  blood  mixed  with 
saliva  escapes  from  the  mouth.  The  muscles  of  the  larynx  by  their 
contraction  prevent  the  ready  escape  of  air  from  the  compressed  chest, 
and  it  passes  out  with  a  hissing  sound.  In  ten  to  twenty  seconds  clonic 
succeed  the  tonic  convulsions  ;  these  begin  in  the  face,  then  affect  the 
muscles  of  the  body  and  limbs;  the  jaws  open  and  close  violently  and 
rapidly,  the  tongue  may  be  again  wounded ;  breathing  is  stertorous, 
irregular,  and  difficult ;  at  each  expiration  frothy  saliva  flecked  with 
blood  may  be  thrown  in  spray  over  the  clothing  of  the  upper  part  of 
the  body;  jerking  movements  ot  the  muscles  of  the  body  and  limbs 
occur  rapidly.  The  sudden  transition  from  calm  to  storm  is  not  more 
striking  than  the  rapid  transformation  of  the  face  and  expression  ;  the 
convulsions  destroy  every  trace  of  beauty  and  intelligence  that  may  have 
been  present  a  few  minutes  before ;  the  face  is  disfigured  by  "  horrible 
grimaces,"  distorted,  discolored,  and  while  calling  for  pity  and  active 
sympathy,  may  be  even  hideous  or  repulsive. 

Whether  the  muscles  of  organic  life  are  affected  by  convulsive  move- 
ments or  not,  is  a  question  in  regard  to  which  difference  of  opinion 
exists ;  if  they  are,  the  explanation  of  the  passage  of  the  feces  or  of 
urine,  occurring  in  some  cases,  is  obvious ;  but  if  they  are  not,  such 
evacuations  are  to  be  attributed  to  the  convulsive  action  of  the  dia- 
phragm and  of  the  abdominal  muscles.  Braxton  Hicks1  states  that  in 
one  case  of  eclampsia,  occurring  in  the  sixth  month  of  pregnancy, 
"  when  an  attack  of  convulsions  came  on  the  uterus  became  intensely 
firm,  and  so  remained  for  the  space  of  ten  to  fifteen  minutes  without 
any  change,  after  which  it  slowly  subsided  into  the  ordinary  condition 
of  gentle  contraction  with  relaxation."  Similar  phenomena  were  ob- 
served by  him  in  another  case. 

There  is  not  an  abrupt  arrest  of  the  disordered  movements  of  the 
clonic  stage  of  eclampsia,  but  they  first  lessen  in  violence  and  frequency, 
then  cease.  Their  duration  is  generally  from  one  to  two  minutes,  but 
it  may  be  five  minutes,  and  Tarnier  once  found  it  twenty  minutes. 
According  to  Cazeaux,  the  pulse  is  full  and  strong  at  the  beginning  of 
the  attack,  but  this  is  probably  not  the  rule ;  in  either  case  it  becomes 

i  Transactions  of  the  London  Obstetrical  Society,  vol.  xxv. 


ECLAMPSIA.  409 

weak,  small,  and  almost  imperceptible  with  the  progress  of  the  convul- 
sive phenomena. 

During  the  attack  the  patient  is  insensible  to  the  most  powerful 
external  excitants;  she  can  neither  see,  nor  hear,. nor  feel.  Coma  or 
stupor  follows  the  clonic  convulsions,  the  duration  of  the  coma  being 
proportional  to  the  severity  of  the  attack.  In  most  cases  within  half 
an  hour  after  the  convulsive  movements  have  ceased  the  patient  wakens, 
at  first  into  a  sort  of  semi-consciousness ;  she  looks  upon  those  sur- 
rounding her  bed,  and  does  not  at  once  recognize  them  ;  when  the 
recognition  comes,  she  does  not  understand  the  anxiety  which  their 
countenances  so  often  betray  ;  her  face  has  a  sadly  bewildered  expres- 
sion ;  the  past,  so  far  as  the  convulsions  are  concerned,  is  a  perpetual 
blank,  and  the  present  a  temporary  cloud.  In  rare  cases  the  patient's 
recovery  immediately  begins,  and  is  rapid  and  perfect.  But  in  the 
majority  eclampsia  is  not  limited  to  a  single  attack  ;  other  attacks  gen- 
erally follow,  the  intervals  varying  from  a  few  minutes  to  several  hours ; 
the  attacks  may  be  so  rapid,  the  intervals  so  brief,  that  the  patient 
passes  directly  from  coma  to  convulsions  without  a  moment  of  even 
partial  consciousness  intervening.  The  coma  becomes  more  profound 
with  the  successive  attacks.  It  is  caused  by  cerebral  congestion ;  the 
congestion  results  from  the  arrest  of  respiration  and  from  the  impeded 
return  of  blood  from  the  brain  arising  from  compression  of  the  jugulars 
by  convulsed  muscles  of  the  neck ;  in  addition  to  cerebral  congestion, 
there  may  be  serous  effusion.  The  number  of  attacks  may  be  only  two 
or  three,  or  ten  to  twenty,  or  there  may  be  one  hundred  and  even  more; 
Charpentier  refers  to  a  case  observed  by  Crettet,  in  which  there  were 
one  hundred  and  sixty.  Ahlfeld  had  a  patient  who  recovered  after 
eighty-two  attacks,  and  Olshausen  one  that  died  after  one  hundred  and 
two.  Pajot  and  Bailly  have  each  had  a  patient  in  whom  more  than  one 
hundred  convulsive  attacks  occurred,  yet  both  patients  recovered. 

The  urine,  which  is  usually  scanty,  in  84  per  cent,  contains  albumin ; 
in  some  cases  it  is  smoke-colored  or  red  from  the  presence  of  blood. 
The  pulse  varies  in  frequency  from  100  to  140 ;  even  this  last  number 
may  be  exceeded.  The  temperature1  progressively  increases  during  the 
continuance  of  the  attacks ;  it  may  reach  104°  F.,  or  go  even  higher, 
and  after  death  still  greater  elevation  of  temperature  is  usually  found. 

The  elevation  of  temperature  has  been  by  some  attributed  to  the 
violent  and  great  muscular  action,  and  by  others  explained  as  a  mani- 
festation of  the  poisoning. 

TERMINATIONS.  MATERNAL  AND  FCETAL  MORTALITY.  Eclamp- 
sia usually  terminates  within  forty-eight  hours,  and  the  great  majority 
of  patients  recover.  Death  may  occur  from  asphyxia  during  a  pro- 
longed tonic  convulsion,  but  this  is  rare ;  the  majority  of  patients  die 
during  coma  by  a  "  slow  asphyxia."  Others  die  from  congestion  or 

1  Jean  Robin  (Paris  Thesis,  1883)  remarks,  in  referring  to  the  temperature  in  the  diagnosis  of 
eclampsia :  "  M.  Bourneville  has  shown  that  the  temperature  is  progressively  elevated  in  eclamp- 
sia, and  attains  even  after  death  the  great  degree  of  109°  F."  This  would  be  a  valuable  sign  as  an 
element  of  diagnosis  if  met  wjth  in  all  cases,  for  nothing  similar  occurs  in  uraemia,  where,  on  the 
contrary,  the  temperature  is  lowered.  Unfortunately,  in  a  quite  recent  observation,  it  completely 
felled.  We  see,  in  fact,  that  the  temperature  did  not  pass  99.5°  F.  (Thesis  of  Oaix,  Paris.) 

Winckel  first  called  attention  to  elevation  of  temperature  in  eclampsia.  But  both  in  diagnostic 
and  prognostic  value  this  sign  is  by  no  means  constant.  For  example,  in  a  case  occurring  under 
my  care  at  the  Philadelphia  Hospital,  and  proving  fatal,  the  temperature  was  usually  less  than 
101°,  only  once  reaching  102° ;  an  hour  after  death  it  was  98.8°. 


410  THE  PATHOLOGY  OF  PREGNANCY. 

cerebral  hemorrhage.  Pulmonary  oedema  is  in  many  the  cause  ;  still  others 
perish  later  from  deglutition  pneumonia.  The  eclamptic  is  more  liable 
to  post-partum  hemorrhage  and  to  puerperal  accidents,  aud  a  number 
surviving  the  convulsions  perish  from  puerperal  infection.  Even  though 
the  patient  should  not  die  from  eclampsia  or  its  immediate  consequences, 
her  recovery  may  be  incomplete,  for  diseases1  of  the  psycho-motor  or 
psycho-sensorial  centres,  as  amaurosis,  aphonia,  hemiplegia,  neuralgia, 
psychoses,  may  follow.  "  In  the  Guy's  Charity  the  mortality  was  50 
per  cent,  in  cases  which  began  before  the  onset  of  labor,  25  per  cent,  in 
those  which  began  during  labor,  and  only  8  per  cent,  in  those  which 
began  after  delivery,  the  total  mortality  being  25  per  cent."  Auvard 
regards  the  mortality  as  25  per  cent.,  while  Winckel  states  that  with 
the  improved  methods  of  treatment  of  the  last  ten  years  it  is  only  7  to 
10  per  cent.  Ahlfeld  considers  the  mortality  about  30  per  cent.,  and 
so,  too,  Kalteubach  ;  Lohlein,  19.38 ;  Olshausen,  25  ;  Schauta,  36.50. 
The  foetal  mortality  is  26  to  70  per  cent.  The  death  of  the  foetus  may 
be  from  placental  changes,  so  frequent  in  renal  diseases,  as  has  been 
pointed  out,  especially  from  hemorrhages  involving  the  placenta,  or,  it 
may  be  caused  by  asphyxia ;  and  of  course  such  asphyxia  will  be  more 
liable  to  occur  if  the  eclamptic  attacks  are  frequent,  severe,  and  pro- 
longed. According  to  Viuay,  the  most  frequent  cause  is  the  poison- 
ing of  the  maternal  blood  and  the  transmission  to  the  foetus  of  this 
poison.  He  refers  to  several  facts  proving  the  intoxication  of  the 
foetal  blood.  Children  have  been  born  of  eclamptic  mothers,  with 
rigidity  of  the  muscles,  contractures.  I  have  myself  witnessed  a  case 
of  this  kind  ;  others  born  hemiplegic  ;  albumin  has  been  found  in  the 
urine  of  the  foetus ;  finally,  the  child  has  been  born  in  apparently  good 
condition,  and  in  a  short  time  afterward  attacked  with  convulsions  simi- 
lar to  those  of  the  mother,  and  the  autopsy  often  reveals  the  lesions 
observed  in  eclamptic  women  who  have  died. 

The  chance  of  the  foetus  surviving  is  little  better  if  the  mother  is 
attacked  during  than  before  labor. 

PROGNOSIS.  This  is  more 'favorable  if  the  disease  occurs  after  labor 
than  during,  and  especially  before  labor.  It  is  rendered  graver  by  the 
frequency  and  severity  of  the  attacks,  by  the  profoundness  of  the  inter- 
vening coma,  by  the  urine  being  scanty  and  containing  much  albumin, 
by  great  oedema,  and  by  the  temperature  steadily  increasing ;  it  should 
be  remembered,  however,  that  in  some  cases  eclampsia  proves  fatal, 
though  the  temperature  may  vary  little  from  the  normal.  Schroder  re- 
garded the  pulse  as  furnishing  the  most  important  prognostic  indication. 
As  long  as  this  remains  hard  and  full,  though  moderately  frequent,  there 
is  no  immediate  danger;  but  if  it  be  frequent,  small,  aud  easily  com- 
pressed, the  prognosis  is  almost  absolutely  bad.  Kaltenbach  regards  as 
especially  indicating  an  unfavorable  prognosis,  complete  anuria,  pro- 
found stupor,  loss  of  reflex  irritability,  paralysis,  small,  frequent  pulse, 
great  elevation  of  temperature,  jaundice.  The  prognosis  is  more  un- 
favorable if  there  be  a  complication,  such  as  cardiac  or  pulmonary  dis- 
ease. Winckel  states  that  the  death  of  the  child  improves  the  prognosis 
in  eclampsia  occurring  in  pregnancy. 

1  Kaltenbach. 


ECLAMPSIA.  4H 

In  connection  with  the  fact  just  stated,  it  is  of  interest  to  refer  to  a  paper1  by 
Barbour,  the  report  of  a  case  of  diminution  of  albuminuria  in  pregnancy  coinci- 
dent with  the  death  of  the  foetus.  The  author  adduces  three  similar  cases 
observed  by  Underbill,  McLaren,  and  Spiegelberg 

PATHOLOGICAL  APPEARANCES.  Autopsies  do  not  establish  the 
nature  of  the  disease. 

In  exceptional  cases  the  kidneys  may  be  normal,  but  in  the  great 
majority  they  present  changes  characteristic  of  all  forms  of  nephritis, 
from  the  slightest  to  the  gravest.  Nevertheless  the  eclamptic  manifes- 
tations are  not  in  proportion  to  the  gravity  of  these  changes  as  ascer- 
tained after  death.  Schauta,  in  twenty-eight  cases  of  fatal  eclampsia, 
found  nine  of  ansemia  of  the  kidneys ;  in  sixteen  the  lesions  of  Bright' s 
disease,  and  in  three  the  organs  were  healthy.2  Vinay  observes  that 
the  results  of  microscopic  examination  prove  that  in  rather  a  large  num- 
ber of  cases  of  eclampsia  the  disease  can  hardly  be  attributed  to  a  renal 
lesion. 

The  brain  may  frequently  show  no  important  change.  In  some  there 
may  be  found  cedema  and  anaemia — more  rarely  hyperamia  and  still 
more  seldom  hemorrhage. 

The  lungs  may  show  lobular,  more  seldom  lobar  pneumonia,  and 
hemorrhagic  infarcts ;  they  are  frequently  redematous. 

In  the  liver  Nikoroff3  found  scattered  thromboses  of  the  inter- 
acinous  capillary  vessels,  with  necrosis  of  the  liver  cells,  and  hemor- 
rhages, as  well  as  thrombi  in  the  small  venous  vessels.  Further,  the 
liver  may,  in  some  cases,  present  the  changes  characteristic  of  acute  yel- 
low atrophy.  In  some  cases  the  ureters  have  been  found  greatly  dilated. 

ETIOLOGY.  It  is  necessary  to  divide  the  causes  of  eclampsia  into 
predisposing,  exciting,  and  essential,  for  only  thus  can  some  of  the  con- 
tradictory or  exclusive  theories  of  its  origin  be  reconciled. 

1.  Predisposing  Causes.  Primiparity4  ranks  first  among  these  causes, 
eclampsia  being  three  or  four  times  more  frequent  in  a  first  than  in 
other  pregnancies.  Pluriparity  is  also  a  predisposing  cause,  and  thus 
women  pregnant  with  twins  or  triplets  have  ten  times  greater  liability 
to  eclampsia  than  if  the  uterus  contains  but  one  foetus.  Ahlfeld  calls 
attention  to  the  fact  that  a  short  woman,  her  uterus  greatly  enlarged,  is 
especially  exposed  to  the  disease.  Lohlein  asserts  that  women  with 
narrowed  pelves  are  very  liable  to  eclampsia.  Hereditary  influence  has 
been  shown  a  factor  in  some  cases.  The  late  Dr.  George  T.  Elliot 
narrates  the  history  of  a  mother  and  her  four  daughters  who  had  eclamp- 
sia ;  and  L5hlein  mentions  the  instance  of  three  sisters  who  suffered 
similarly.5  There  is  in  some  organizations  a  liability  to  neurotic  disorder, 
and  this  may  assist,  not  cause,  eclampsia.  Possibly  the  mental  condi- 
tion may  predispose  to  the  affection,  and  this  may  explain  an  increased 
danger  of  unmarried  women,  as  held  by  some.  In  consequence  of  in- 

1  Edinburgh  Obstetrical  Society's  Transactions,  vol  x. 

2  Ahlfeld  in  17  cases  of  eclampsia  had  2  without  any  disease  of  the  kidneys. 

3  Jahresbricht  iiber  die  Fortschritte  auf  dem  Gebiete  der  Geburtshilfe  und  Gynakologie,  1894. 

4  In  fifteen  years,  1874  to  1889,  2655  women  were  delivered  at  the  Philadelphia  Hospital,  and  there 
were  9  cases  of  eclampsia,  or  1  in  295.    But  the  9  were  primiparae.    I  am  indebted  to  D.  J.  L.  Roth 
rock,  one  of  the  resident  physicians  at  the  hospital  for  furnishing  me  with  these  statistics. 

5  Stewart,  Lancet,  1893,  met  with  eclampsia  in  two  sisters,  each  a  prinripara. 


412  THE  PATHOLOGY  OF  PREGNANCY. 

creased  reflex  excitability  of  the  nervous  system  the  liability  to  eclamp- 
sia is  greater. 

Exciting  Causes.  Given  a  condition  of  unstable  equilibrium,  a  com- 
paratively trifling  cause  may  destroy  that  equilibrium  ;  and  thus  we 
find  in  some  cases  abdominal  palpation,  or  vaginal  examination,  move- 
ments of  the  child,  or  a  distended  bladder  may  immediately  result  in  an 
attack.  So  far  as  the  convulsions  follow  a  uterine  contraction,  possibly 
this  action  of  the  uterus  is  not  to  be  explained  so  much  by  the  local 
irritation,  but  by  the  fact  that  contraction  throws  into  the  maternal  circula- 
tion from  the  placenta  new  poison  originating  in  it  or  derived  from  life- 
changes  in  the  foetus. 

A  contribution1  to  the  nervous  origin  of  eclampsia  has  been  made  by  Lantos, 
from  material  collected  in  the  obstetric  and  gynecological  clinic  of  Professor 
Kegmarszky,  at  Budapesth.  According  to  Lantos,  albuminuria  in  the  course  of 
pregnancy  and  of  labor,  independently  of  all  morbid  changes  in  the  kidneys,  is 
not  a  rare  phenomenon,  and  is  even  very  frequent  during  labor.  Eclampsia 
occurred  once  in  278  cases,  the  entire  number  of  labors  being  14,815,  and  15 
died — 28.3  per  cent.  The  mortality  was  greater  after  artificial  delivery.  He 
regards  the  disease  as  an  acute  peripheral  epilepsy.  The  albuminuria  and  the 
eclampsia  have  a  common  origin ;  irritation  of  uterine  nerves  is  reflected  to  the 
kidneys  and  acts  upon  their  vaso-constrictors,  and  thence  albuminuria ;  or  upon 
the  medulla,  and  convulsions  result. 

Do  not  facts  previously  mentioned,  e.  g.,  uterine  palpation  or  vaginal  touch, 
prove  the  reflex  origin  of  eclampsia  ?  Various  agents  may  cause  the  explosion 
of  a  powder  magazine— an  electric  spark  not  less  than  the  blazing  fire  or  the 
lighted  match  or  the  falling  spark ;  but  without  the  powder  explosion  would 
be  impossible.  Thus,  in  the  eclamptic,  when  reflex  irritation  apparently  is  the 
cause  of  the  convulsive  seizure,  there  is  a  condition  of  unstable  equilibrium 
resulting  from  prior  cause,  and  that  equilibrium  is  readily  disturbed  by  an  agent 
which,  under  ordinary  circumstances,  would  be  powerless. 

The  Essential  Cause.  The  generally  accepted  view  of  eclampsia  is 
that  it  is  produced  by  toxemia.  The  theory  of  blood-poisoning,  as 
Kaltenbach  has  said,  is  sustained  by  the  clinical  history  and  by  the  post- 
mortem appearances.  "  The  prodromal  gastric  and  cerebral  disorders, 
the  rapid  and  profound  disturbances  of  the  action  of  the  brain,  the 
post-mortem  elevations  of  temperature,  the  character  and  frequency  of  dis- 
eases of  the  nervous  system  which  follow,  that  are  similar  to  the  neuroses 
after  typhus  and  diphtheria,  probably  caused  by  a  toxalbumin,  are  best 
explained  by  accepting  the  hypothesis  of  toxemia." 

What  this  poison  is,  or  conceding  more  than  one  toxic  agent,  what 
these  poisons  are,  and  what  the  origin,  are  questions  still  unanswered. 

We  perpetuate  in  the  title  ursemic,  once  generally,  and  still  often,  applied  to 
eclampsia,  the  view  that  retention  of  urea  in  the  blood  is  the  essential  cause. 
Winckel  has  said  that  there  is  no  evidence  of  retention  of  urea  in  the  most  im- 
portant organs,  especially  in  the  liver  and  muscles;  on  the  contrary,  these 
contained  less  urea  than  normally,  and  in  cases  of  eclampsia  that  recovered  the 
amount  of  nitrogen  excreted  in  the  urine  was  only  equal  to  the  minimum  quan- 
tity excreted  in  a  state  of  absolute  hunger.  While  urea  is  a  poison,  the  quantity 
necessary  to  cause  serious  injury  is  very  great.  Though  the  pregnant  woman 
excretes  nearly  one-third  more  than  the  non-pregnant,  at  least  ten  days  must 
elapse  without  elimination  in  order  that  toxic  effects  can  result2  Moreover,  in 
uraemic  poisoning  the  temperature  does  not  increase,  while,  as  a  rule,  in  the 
eclamptic  it  does. 

1  Archiv  f.  Gyn.,  vol.  xxiii.  -  Rivifere. 


ECLAMPSIA.  413 

When-,  many  years  ago,  Frerichs,  finding  the  urteinic  theory  destroyed,  sug- 
gested that  urea  was  broken  up,  and  ammonia  formed,  and  that  this  was  the  toxic 
agent,  the  convulsions  being  ammoniemic,  he  advised  as  prophylactic  means  the 
administration  of  vegetable  acids,  more  especially  benzoic  and  citric.  The  false, 
misleading  name  unemic  has  been  retained ;  and  equally  wrong  are  those  doctors 
who  cling  to  the  Frerichs  treatment,  apparently  not  knowing  that  the  theory 
upon  which  it  was  founded  has  long  since  perished. 

Riviere1  teaches  that  eclampsia  occurs  from  auto-intoxication,  and  this 
doctrine  is  also  held2  by  Auvard.  That  it  contains  only  part  of  the 
truth  will  be  shown  in  the  further  discussion  of  the  subject. 

The  toxsemic  theory  rests  upon  the  fact  that  there  are  constantly 
developed  in  life-processes  substances  which  must  be  eliminated,  various 
organs  being  concerned  in  this  process  of  elimination.  If  one  or  more 
of  these  organs  fail  in  their  function,  and  it  is  impossible  for  others  to 
act  vicariously,  a  toxaemia  results ;  hence  there  is  auto-intoxication. 
Riviere  thus  presents  the  foundation  of  the  toxsemic  theory  of  eclampsia : 

1.  The  organism  receives  and  makes  without  ceasing  poisons,  which  the  liver 
destroys  in  part,  but  which  are  chiefly  eliminated  by  the  cutaneous,  pulmonary, 
intestinal,  and  renal  emunctories.     The  value  of  these  different  emunctories  is 
not  the  same;  the  renal  filter  certainly  enjoys  the  preponderating  role. 

2.  These  products  of  elimination  are  all  toxic,  as  clearly  proved  by  experi- 
ment; but  their  toxicity  constantly  varies  in  the  same  individual  according  to 
the  functional  state  of  the  different  emunctories  and  according  to  diverse  special 
conditions. 

3.  These  poisons  being  multiple  and  of  diverse  origins,  the  intoxication  pro- 
duced by  their  retention  in  the  organism  is  and  ought  to  be  complex,  and  may 
present  several  forms. 

4.  Eclampsia  is  one  of  the  forms  of  this  intoxication. 

It  seems  probable  that  failure  in  elimination  by  the  skin,  the  lungs, 
and  intestines  cannot  have  the  important  part  in  the  production  of 
eclampsia  that  belongs  to  similar  failure  of  the  liver  and  kidneys,  and 
possibly,  as  Auvard  suggests,  there  is  one  renal  and  one  hepatic  eclamp- 
sia. In  regard  to  the  poison  or  poisons  which,  retained  in  the  system, 
may  cause  eclampsia,  we  are  ignorant.  Winckel  remarks  that  there  are 
not  only  great  diiferences  in  the  degree  of  intoxication,  but  probably 
also  various  poisons,  or,  at  least,  one  poison  arising  in  different  ways  in 
the  body  of  the  pregnant  woman,  which  may  be  the  cause  of  the  disease. 
In  connection  with  this  topic  the  observations  of  Stumpf3  should  be 
mentioned.  He,  from  original  investigations,  concluded  that  under 
abnormal  processes  of  decomposition,  a  substance  free  from  nitrogen, 
toxic  in  its  action,  perhaps  acetone,  or  a  body  resembling  it,  reacting  to 
the  same  tests,  may  be  formed,  which  produces  in  its  excretion  an  irrita- 
tion of  the  kidneys  that  may  finally  cause  nephritis,  has  a  destructive 
effect  upon  the  coloring-matter  of  the  blood,  greatly  alters  the  activity 
of  the  renal  cells,  causes  sugar  to  appear  in  the  urine,  and  produces 
destruction  of  the  parenchyma  of  the  liver,  advancing  to  acute  yellow 
atrophy  with  the  formation  of  tyrosin  and  leucin,  and  induces  coma 
and  convulsions  from  an  irritation  of  the  brain.  Nevertheless  he  does 
not  regard  this  view  as  applicable  to  all  cases  of  eclampsia. 

1  Pathogenic  et  traitement  de  1'auto-intoxication  eclamptique.    Paris,  1888. 

2  Traite  pratique  d'Accouchements.    Paris,  1890.  3  Winckel. 


414  THE  PATHOLOGY  OF  PREGNANCY. 

The  disease  should  be  regarded  as  essentially  a  toxaemia,  the  poison- 
ing resulting  in  some  eases  from  a  failure  of  one  or  more  eliminating 
organs  to  exercise  perfectly  their  function.  By  the  light  of  this  theory 
possibly  we  may  see  why  in  case  of  the  death  of  the  foetus,  if  the  eclamp- 
tic  attacks  occur  in  pregnancy,  they  cease,  or  if  albuminuria  has  occurred 
it  lessens  or  disappears.  While  the  foetus  lived  it  was  constantly  throw- 
ing into  the  mother's  blood  materials  which  ought  to  be  eliminated 
through  her  emuuctories.  But  if  the  foetus  dies,  this  process  no  longer 
goes  on,  the  mother  has  only  to  eliminate  self-created  poisons,  and  the 
organs  concerned  are  adequate  to  this  single  work,  though  they  failed 
when  the  double  burden  was  cast  upon  them. 

Admitting  that  the  poison  causing  eclampsia  may  originate  in  the 
foetus  or  in  its  appendages,  including  especially  the  placenta,  we  have  a 
partial  explanation  of  the  greater  frequency  of  the  disease  in  plural 
pregnancy,  and,  as  before  suggested,  of  an  exciting  cause  being  found 
in  uterine  contractions,  for  these  result  in  more  of  the  poison  entering 
the  mother's  blood,  in  consequence  of  compression  of  the  uterus. 

If  this  view  be  correct,  while  still  upholding  the  doctrine  of  toxasmia 
as  the  best  explanation  of  the  etiology  of  puerperal  convulsions,  the 
opinion  of  Riviere  that  the  condition  of  the  blood  is  from  auto-intox- 
ication cannot  be  fully  admitted. 

The  view  upheld  by  Gerdes  and  a  few  others,  that  the  toxic  agent  is 
produced  by  a  bacillus — improbable  from  the  fact  that  such  theory  pre- 
supposes an  endometritis,  a  condition  rarely  found  in  the  primigravida, 
while  she  is  much  more  liable  to  eclampsia  than  the  multigravida,  in 
whom  endometritis  oftener  occurs — still  the  essential  etiology  remains, 
that  is,  the  disease  originates  in  toxemia. 

Chambrelent  has  proved1  that  the  toxicity  of  the  blood  serum  of  the 
eclamptic  is  greatly  increased. 

Many  questions  in  the  causation  of  eclampsia  remain  obscure.  For 
example,  Why  should  the  disease  be  more  frequent  in  one  year  than  in 
another  ?  Why  more  frequent  in  some  parts  of  the  country  than  iii 
others  ? 

INFLUENCE  OP  ECLAMPSIA  UPON  PREGNANCY  AND  UPON  LABOR. 
The  continuance  of  pregnancy  in  an  eclamptic  is  quite  exceptional, 
abortion  or  premature  labor  usually  resulting  from  the  disease.  Even 
in  cases  in  which  neither  occurs  immediately,  the  foetus  usually  dies, 
though  it  may  not  be  expelled  until  several  days  afterward.  The  pro- 
gress of  the  labor  is  usually  quickened,  not  because  of  any  increased 
force  of  uterine  contractions  occurring  during  the  convulsive  phenomena, 
but  because  of  the  lessened  resistance  which  accompanies  the  general 
relaxation  occurring  in  the  intervals  between  the  attacks. 

DIAGNOSIS.  Premonitory  symptoms  usually  herald  the  disease ;  in 
the  majority  of  cases  of  eclampsia  the  physician  can,  if  in  previous 
attendance,  give  a  probable  prediction  as  to  its  coming.  Hysterical 
convulsions  will  mislead  only  a  careless  observer,  for  the  past  history 
of  the  subject  is  different ;  the  convulsive  phenomena  in  eclampsia  pur- 
sue a  regular  succession,  there  is  order  in  disorder,  but  in  hysteria  they 

1  Gazette  bebdom.  de  Med.  de  Bordeaux,  1892. 


ECLAMPSIA.  415 

are  irregular,  there  seems  almost  a  capriciousness  in  the  movements ; 
they  may  be  grotesque,  sometimes  ludicrous,  and  the  faee  presents  a 
striking  contrast  with  that  of  the  eclamptic,  horribly  distorted  by  the 
rapid  movements  of  clonic  convulsions.  In  eclampsia  the  convulsive 
movements  end  in  coma ;  in  hysteria  they  may  cease  with  tears  or 
laughter,  or  with  a  profuse  secretion  of  urine.  A  cry  heralds  the  onset 
of  an  epileptic  attack ;  the  history  of  the  patient  tells  of  previous 
attacks;  the  urine  does  not  contain  albumin;  the  coma  is  brief.  If 
coma  result  from  apoplexy,  there  will  be  accompanying  paralysis,  and 
the  urine  does  not  contain  albumin. 

TREATMENT.  This  is  divided  into  prophylaxis,  means  indicated  in 
case  eclampsia  should  occur,  and  finally  the  obstetric  management. 

PROPHYLAXIS.  The  preventive  treatment  is  indicated  in  all  cases 
of  decided  disorder  of  the  renal  function,  especially  in  pregnancy- 
nephritis.  While  eclampsia  may  occur  without  any  album inuria,  and 
the  majority  of  albuminurics  do  not  become  eclamptic,  yet  the  occur- 
rence of  albuminuria  in  gestation,  if  associated  with  lessened  renal 
secretion,  is  always  an  indication  for  the  use  of  means  to  avert  threat- 
ened danger. 

The  milk  diet,  to  the  exclusion  of  all  other  articles  of  food,  should 
be  at  once  directed.  "Milk  is  a  complete  aliment,  reconstituent,  usually 
digested  more  quickly  and  easily  than  any  other,"  and,  as  Riviere  sug- 
gests, does  not  leave  a  toxic  residue  in  the  intestines  which  may  be 
absorbed,  and  from  the  blood  pass  to  the  intestines.  Further,  let  the 
hot  bath,  the  bathing  accompanied  by  drinking  hot  water  or  hot  milk, 
be  employed  every  day,  or  once  in  two  or  three  days;  especially  is  the 
bath  indicated  if  there  be  notable  oedema.  The  bowels  should  be  moved 
daily,  using  the  aloes  and  colocynth  pill  advised  by  Winckel.  Vinay1 
praises  chloral,  stating  that  if  albumin  is  abundant  and  eclampsia 
threatened  4  to  5  grammes  may  be  given  every  twenty-four  hours. 

He  makes  the  following  statement :  "  I  have  employed  this  medicine  during  a 
month,  conjoined  with  milk,  in  a  young  primipara,  who  had  general  anasarca, 
bronchitis  with  pulmonary  congestion,  digestive  disorders,  and  headache ;  thus 
she  took  during  her  ninth  month  120  grammes  of  chloral,  labor  occurred  at 
term,  no  convulsions,  and  the  child  was  living  and  healthy." 

MEDICAL  TREATMENT.  Vinay  justly  remarks2  that  there  are  malig- 
nant forms  of  eclampsia  absolutely  fatal,  and  all  means  are  powerless ; 
there  are  others  that  are  benign,  and  recover  without  reference  to  the 
therapeutic  means ;  and  still  others  of  mean  gravity,  and  their  course 
and  cure  are  influenced  by  the  tYeatment.  During  the  attack  the  ob- 
stetrician should  see  that  the  clothing  of  the  patient  is  loose,  should 
forbid  efforts,  so  often  unwisely  made,  with  the  vain  hope  of  restraining 
her  movements;  but  at  the  same  time  care  must  be  taken  to  prevent  the 
possible  accident  of  her  falling  from  the  bed ;  injury  of  the  tongue  must  be 
guarded  against,  not  by  interposing  cork,  or  rubber,  or  a  spoon,  or  piece 
of  wood  between  the  jaws,  but  by  stretching  a  soft  napkin  between 
them,  from  one  side  to  the  other  of  the  mouth,  so  as  to  keep  the  tongue 
from  protruding. 

1  Traite  des  maladies  de  la  Grossesse,  1894.  2  Op.  cit. 


416  THE  PA  THOL  OQ  Y  OF  PREGNANCY. 

Some  object  to  the  napkin  because  it  prevents  the  entrance  of  air,  preferring 
a  wooden  spoon  interposed  between  the  jaws  to  prevent  biting  the  tongue.  But 
as  entrance  of  air  through  the  nose  is  not  interfered  with  the  objection  does 
not  seem  valid;  moreover,  wooden  spoons  are  rarely  found  in  households  in  this 
country. 

Kaltenbach  regards  it  important  to  wipe  out  the  pharyngeal  cavity 
with  a  small  spouge  fastened  to  a  handle,  as  well  as  turning  the  face  to 
the  side,  to  prevent  the  entrance  of  a  large  quantity  of  the  secretions 
from  the  mouth  and  pharynx,  mixed  with  bloody  slime,  into  the  lungs. 
"If  the  tongue  falls  backward  during  profound  coma,  it  is  to  be  drawn 
forward,  and  immediate  relief  to  respiration  is  thus  given."  As  soon 
as  possible  an  active  cathartic  is  usually  given,  and  also  a  stimulating 
enema. 

Bleeding  was  formerly  regarded  by  most  authorities  as  the  essential 
treatment  of  eclampsia,  but  in  recent  years  it  is  absolutely  rejected  by 
some  of  the  best  obstetric  teachers. 

But  may  there  not  be  an  error  on  the  part  of  those  who  reject  this 
means,  as  there  was  on  the  part  of  those  who  employed  it  in  all  cases  ? 
Those  who  always  bled  in  eclampsia  were  undoubtedly  wrong,  but  is  it 
quite  certain  that  those  who  never  bleed  are  invariably  right?  It  may 
be  admitted  that  there  are  very  few  cases  in  which  bleeding  is  advisable, 
but  to  say  that  there  are  none  is,  I  think,  going  too  far.  Venesection 
instantly  removes  a  certain  amount  of  toxic  material  from  the  blood, 
whereas  elimination  by  normal  emunctories  is  gradual.  It  relieves  renal 
congestion,  which  may  be  the  immediate  cause  of  the  eclampsia,  and 
cerebral  congestion,  which  may  be  the  consequence  of  the  attack. 
Moreover,  as  pointed  out  by  Peter,  a  dynamic  eifect,  vascular  contrac- 
tion, results  from  bleeding.  If  there  are  not  clinical  facts  proving  the 
value  of  venesection  in  eclampsia,  then  the  statistics  adduced  by  Char- 
pentier  must  be  rejected. 

The  teaching  of  that  wise  obstetrician,  the  late  Dr.  Fordyce  Barker, 
upon  this  question,  I  think,  may  be  accepted :  "When  the  attack  occurs 
before  labor,  if  the  pulse  be  strong  and  hard,  with  great  fulness  of  the 
vascular  system,  and  the  appearance  of  the  face  indicates  vascular  con- 
gestion, bleed  at  once."  It  should  be  remembered,  however,  that 
whether  venesection  be  employed  before  or  during  labor,  copious  deple- 
tion is  not  advisable,  the  results,  according  to  Charpentier's  statistics, 
being  more  favorable  if  it  be  moderate. 

Ahlfeld  commends  bleeding  in  pulmonary  osdema,  and  Kaltenbach  has  said 
that  it  has  a  beneficial  effect  in  strong,  plethoric  subjects  with  great  cyanosis. 
Martin,  on  the  other  hand,  has  seen  no  benefit  from  it,  and  Winckel  states  that 
he  has  long  since  abandoned  it,  for,  even  in  pulmonary  oedema,  if  venesection  be 
employed  it  weakens  the  power  of  the  heart. 

The  hot  bath  is  warmly  recommended  by  Breus.  The  patient  is  kept 
for  half  an  hour  in  a  bath,  the  temperature  at  first  being  from  100.4°  to 
104°  F. ;  then  the  temperature  is  gradually  increased  by  adding  hot 
water  to  113°  ;  she  is,  after  being  taken  out  of  the  bath,  wrapped  in 
hot  sheets  and  blankets.  She  perspires  freely,  and  the  coma  and  oedema 
disappear.  As  before  stated,  the  hot  bath  is  of  especial  value  in  avert- 
ing a  threatened  attack. 


ECLAMPSIA.  417 

The  treatment  of  eclampsia  most  generally  accepted  is  the  employ- 
ment of  narcosis,  in  order  to  lessen  the  irritability  of  nervous  centres. 
The  agents  usually  used  are  morphine,  chloral,  and  chloroform.  The 
first  is  given  hypodermatically,  and  the  last  by  inhalation.  Opiates 
were  administered  in  eclampsia  by  some  of  the  older  obstetricians,  but 
it  is  especially  to  Clark,  of  Oswego,  N.  Y.,  and  to  G.  Veit,  of  Bonn, 
that  we  are  indebted  for  the  heroic  doses  of  morphine.  Clark  directed 
an  injection  into  the  arm  of  one  grain  and  a  half;  if  the  attacks  re- 
turned at  any  time  within  two  hours,  the  dose  was  repeated,  and  if  the 
patient  is  in  labor  another  dose  is  given  in  eight  hours.  Veit  gives  at 
first  not  less  than  0.03  to  0.04  centigramme,  or  0.463  grain  to  0.617; 
and  within  four  to  seven  hours  increases  it  to  0.12  to  0.2  centigramme, 
or  1.85  to  3  grains.  The  results  have  been  very  good.  Ahlfeld  em- 
ploys smaller  doses,  frequently  repeated — only  one  centigramme  being 
administered  at  a  time. 

Chloral  is  warmly  advocated  by  Winckel,  and  seems  an  especial 
favorite  with  French  obstetricians.  Winckel  advises  from  one  to  two 
grammes  dissolved  in  water,  to  be  given  by  the  rectum  after  each  attack ; 
until  the  patient  is  brought  under  its  influence  chloroform  inhalation  is 
employed ;  he  does  not  hesitate  to  administer  twelve  grammes  or  more 
in  twenty-four  hours.  Charpentier1  begins  the  treatment  by  moderate 
bleeding,  then  gives  by  the  rectum  four  grammes  of  chloral  in  sixty 
grammes  of  quince  mucilage. 

Vinay  recognizes  the  fact  that  one  of  the  benefits  of  chloral  is  lessen- 
ing arterial  pressure ;  he  believes  that  the  tolerance  of  the  rectum  is 
facilitated  by  administering  it  in  combination  with  the  yelk  of  an  egg, 
thus  for  an  injection  he  directs  one  hundred  grammes  of  warm  milk, 
four  grammes  of  chloral,  and  the  yelk  of  one  egg. 

Chloroform  by  inhalation  is  a  common  practice  in  eclampsia.  It  is 
held  that  prolonged  chloroform  anaesthesia  is  injurious  to  the  subject  in 
that,  as  stated  by  Kaltenbach,  it  leads  to  acute  fatty  degeneration  of  the 
heart  and  other  organs,  and  it  impairs  the  activity  of  the  kidneys. 
Ahlfeld,  Diihrssen,  Runge,  and  others  emphasize  the  dangers  from  the 
continued  employment  of  chloroform,  asserting  that  death  in  some  cases 
of  eclampsia  is  to  be  attributed  to  it. 

In  some  parts  of  our  country  the  tincture  of  veratrum  viride  is 
regarded  as  the  most  important  agent  in  the  treatment  of  eclampsia.  It 
was  first  thus  used  by  Dr.  Baker,2  of  Eufaula,  Alabama,  in  1859. 
Long  a  favorite  remedy  in  the  West  and  South,  it  has  in  comparatively 
recent  years  become  more  employed3  in  other  parts  of  our  country. 

Jewett*  gives  from  ten  to  twenty  minims ;  the  smaller  dose  repeated 
in  half  an  hour  will  suffice  in  the  majority  of  cases.  He  asserts  "  expe- 
rience seems  to  justify  the  statement  that  no  convulsion  will  occur  while 
the  patient  is  sufficiently  under  veratrum  to  hold  the  cardiac  pulsations 
below  sixty  to  the  minute."  Dr.  T.  G.  Davis,  of  Bridgeton,  N.  J.,  has 
reported5  six  cases  successfully  treated  by  hypodermatic  injection  of  six 

1  Traits  pratique  des  Accouchements.  2  Southern  Medical  and  Surgical  Journal,  1859. 

3  See  American  Journal  of  Obstetrics,  1871 ;  New  York  Medical  Journal,  1879 ;  and  Transactions 
of  the  American  Gynecological  Society,  1887. 

4  Transactions  of  the  American  Gynecological  Society,  1887. 
6  Philadelphia  Medical  News,  1893. 

27 


418  THE  PATHOLOGY  OF  PREGNANCY. 

drops  of  tincture  of  veratrum  viride  with  one-third  of  a  grain  of  mor- 
phine in  thirty  minims  of  water,  to  which  six  of  alcohol  had  been  added. 
Undoubtedly  this  combination  of  veratrum  with  morphine  furnishes  one 
of  the  most  encouraging  methods  of  treating  eclampsia.  Of  course,  the 
dose  is  repeated  if  necessary. 

In  regard  to  other  means,  but  little  need  be  said.  Potassic  bromide,  from  its 
slowness  and  its  comparative  feebleness  of  action,  is  to  be  rejected ;  moreover,  it 
may  be  injurious  from  the  potash,  because  that,  according  to  some  views,  exercises 
a  toxic  influence  if  a  considerable  quantity  of  the  salt  is  administered.  The 
nitrite  of  amyl,  first  given1  by  the  late  Dr.  J.  F.  Jenks,  of  Philadelphia,  in  1872, 
and  recommended  by  Dr.  Robert  Barnes  in  his  Lumleian  Lecture,  1873,  has 
failed  to  prove  a  constantly  efficient  agent.  Most  authorities  object  to  pilocar- 
pine  on  account  of  the  abundant  secretion  of  saliva  causing  risks  to  patients  in 
coma,  and  because  of  its  depressing  influence  upon  the  heart.  Bricou,  quoted  by 
J.  Veit,  Miiller's  Handbuch,  employed  pilocarpin  in  twenty-four  cases,  and  seven 
women  died,  four  directly  through  the  influence  of  the  drug. 

There  is  hardly  time  for  the  action  of  diuretics,  and,  according  to  Vinay,  the 
only  one  of  these  deserving  consideration  is  milk.  The  diuretic  action  of  normal 
salt  solution  injected  into  the  connective  tissue,  and  which  has  been  referred  to 
in  considering  the  treatment  of  albuminuria,  the  method  of  Porak  and  Bernheim, 
may  be  employed. 

OBSTETRIC  TREATMENT.  If  labor  has  begun,  hasten  dilatation 
of  the  os  by  means  of  the  fingers  or  some  of  the  rubber-bag  dilators, 
at  the  same  time  preventing  reflex  irritation  by  anaesthesia.  Then  de- 
liver by  forceps,  or  by  podalic  version,  or  perforation  of  the  child,  if 
it  is  dead,  as  soon  as  practicable  without  violence. 

But  shall  the  practice  of  Diihrssen,  forced  dilatation,  deep  cervical 
incisions,  and  high  forceps,  be  adopted?  Ahlfeld  warns  against  it. 
Charpentier,  more  especially  considering  the  induction  of  premature 
labor,  as  advocated  by  Diihrssen,  states1  that  it  should  be  reserved  for 
some  exceptional  cases  in  which  the  medical  treatment  has  failed.  He 
gives  the  following  statistics  of  the  mortality  in  eclampsia  :  After  spon- 
HIS  labor,  18.96  per  cent. ;  after  induced  labor,  30.04  per  cent. ; 
Jafter  accouchement  force,  40.74  per  cent.  Kaltenbach  regards 
larean  section  as  preferable  to  forced  extraction  of  the  child  after 
deep  incisions  of  the  cervix  and  the  vaginal  vault. 

In  deciding  the  question  of  active  obstetric  interference  if  convulsions 
occur  in  pregnancy,  we  must  remember  that  in  some  cases  the  convul- 
sions cease,  and  the  pregnancy  goes  to  term,  when  a  living  child  is  born ; 
and  that  in  others  the  convulsions  may  cease  if  the  child  dies,  and  then, 
too,  the  kidneys  usually  recover  their  normal  condition,  the  albuminuria 
disappearing.  Gooch's  advice  was,  "  Take  care  of  the  convulsions,  and 
let  the  uterus  take  care  of  itself."  Runge  takes  the  ground  that  induc- 
tion of  premature  labor  is  to  be  rejected,  at  all  events  only  to  be  brought 
in  consideration  in  very  severe  cases.  Winckel  regards  the  induction  of 
labor  as  unjustifiable.  Certainly  most  practitioners  will  take  the  view 
expressed  by  Charpentier,  rather  than  immediately  arrest  the  pregnancy. 

At  the  Berlin  International  Congress,  1890,  Halbertsma  reported  six 
cases  in  which  the  Csesarean  operation  was  done  in  eclamptics.  Several 

i  Philadelphia  Medical  Times,  1872.  «  Nouv.  Arch.  d'Obst<it.  et  Gyn.,  1893. 


ECLAMPSIA.  419 

times  since  then  the  operation  has  been  employed,  and,  according  to 
Viuay,  excluding  those  performed  when  women  were  dying,  there  are 
now  eleven  cases,  with  four  deaths.  The  operation  is  not  indicated  if 
the  child  be  dead,  and  is  justifiable  only  when  the  condition  of  the 
womb  will  not  permit  prompt  vaginal  delivery  and  after  the  failure  of 
medical  treatment. 

In  eclampsia  occurring  after  labor  chloral  or  morphine  will  probably 
be  used,  and  in  some  cases  inhalation  of  chloroform  ;  very  good  results 
have  here  been  had,  too,  by  the  use  of  veratrum  viride. 

Is  the  Caesarean  operation  to  be  done  if  a  woman  is  dying,  with  the 
hope  of  saving  the  child  ?  Possibly  we  may  hasten  the  mother's  death  ; 
possibly,  too,  she  may  be  only  apparently  dying,  and,  finally,  the  uncer- 
tainty of  the  child's  continuing  to  live,  exposed  to  the  perils  it  has  been 
from  the  mother's  condition,  unite  in  giving  a  negative  answer  to  the 
question  ;  in  order  to  give  an  affirmative,  there  must  be  the  infallibility 
which  Coleridge1  declared  necessary  for  the  performance  of  the  operation 
in  general. 

Should  the  mother  die,  the  delivery  of  the  child  by  this  operation  is 
indicated,  unless  it  can  be  as  quickly  delivered  through  the  natural  pass- 
age. The  operation  need  not  be  done  unless  the  child  has  reached  the 
viable  age,  and  is  living. 

The  labor  ended,  and  the  convulsions  ceased,  the  coma  which  may 
remain  will  be  best  treated  by  diaphoretics  and  milk  diet. 

1  In  Coleridge's  Table  Talk  the  following  passage  is  found :  "I  think  there  are  only  two  things 
wanting  to  justify  a  surgeon  in  performing  the  Csesarean  operation  :  first,  that  he  should  possess 
infallible  knowledge  of  his  art ;  and  secondly,  that  he  should  be  infallibly  certain  that  he  is 
infallible." 


CHAPTER  IY. 

CHRONIC  AND  ACUTE  DISEASES  IN  PREGNANCY. 

UNDER  the  head  of  chronic  diseases  occurring  in  gestation  will  be 
included  those  that  were  present  before  gestation,  or  began  during  it. 

DISEASES  OF  THE  HEART.  As  has  been  previously  stated,  hyper- 
trophy of  the  heart  is  a  normal  phenomenon  of  pregnancy.  This  has 
recently  been  conclusively  proved  notwithstanding  previous  disputes. 

Dreysel1  from  the  examination  of  67  hearts  of  women  dying  in  pregnancy  and 
in  lying-in,  proved  that  as  a  rule  both  ventricles  undergo  slight  excentric  hyper- 
trophy, the  left  more  than  the  right.  Heart  hypertrophy  prevails  in  young,  strong 
women,  increases  with  the  duration  of  pregnancy  to  birth,  then  at  first  rapidly 
lessens,  afterward  slowly. 

It  has  been  thought  possible  that  in  exceptional  cases  normal  cardiac, 
like  uterine  involution,  may  be  imperfect,  and  persisting  hypertrophy 
may  become  permanent  in  consequence  of  rapidly  recurring  pregnancies. 
Now  the  tendency  of  hypertrophy  of  the  left  heart  is  to  increase  the  di- 
ameter of  the  aortic  and  that  of  the  mitral  orifice,  and  hence  valvular 
insufficiency  may  result. 

The  cardiac  disease  in  most  cases  is  rheumatic  in  origin,  and  ante- 
dated pregnancy,  but  the  latter  reveals  the  former,  that  is  to  say,  a 
crippled  heart  may  cause  no  serious  disturbance  in  the  non-pregnant 
condition,  but  when  pregnancy  occurs  it  is  unequal  to  the  increased 
work  thrown  upon  it,  and  what  Peter  has  first  called  cardiopathic  acci- 
dents result.2  The  pregnant  woman's  heart,  it  has  been  said,  beats  for 
two,  as  her  lungs  breathe  for  two.  "  There  is  consequently  greater 
pressure  in  the  vascular  system  of  these  organs,  a  necessary  congestion, 
and  this  new  anatomical  condition  resulting  from  the  needs  of  hsema- 
tosis  for  two  gives  a  satisfactory  explanation  of  the  suffocations  which 
some  pregnant  women  experience,  and  of  the  pulmonary  hemorrhages 
which  occur  in  others."  In  fourteen  cases  reported  by  Peter,  the  form 
of  lesion  in  almost  all  was  mitral  insufficiency  with  or  without  stenosis, 
and  once  only  in  the  fourteen  was  there  aortic  insufficiency.  The  time 
when  gravido-cardiac  accidents  begin,  or  become  very  intense,  is  from 
the  third  to  the  sixth  month,  generally  in  the  fifth.  MacDonald3  holds 
that  serious  symptoms  do  not  usually  appear  until  after  the  middle  of 
pregnancy  ;  they  are  apt  to  be  aggravated  by  exposure  to  cold  or  by 
exertion,  and  patients  suffering  from  severe  cardiac  lesions  almost  always 
are  delivered  prematurely. 

While  the  statistics  of  observers  confirm  the  statement  of  Peter  as  to  the  lesion 
being  more  frequently  mitral  than  aortic,  yet  they  do  not  make  the  proportion  so 

1  Munch,  med.  Abhand,  1891.  *  Maladies  du  Coeur,  et  de  la  Crosse  de  1'Aorte,  1883. 

8  Chronic  Disease  of  the  Heart  in  Reference  to  Pregnancy  and  Parturition. 


CHRONIC  AND  ACUTE  DISEASES  IN  PREGNANCY.  421 

great  as  his  statistics  did.     Thus  Berthiot1  gives  only  22  out  of  36  as  mitral ; 
Porak'2  found  57  mitral,  22  complex,  and  13  aortic. 

Gravido-cardiac  accidents  are  rarely  seen  in  first  pregnancies,  but 
their  frequency  and  severity  increase  from  the  second  in  subsequent 
pregnancies.  The  danger  from  cardiac  disease  is  greatest,  probably,  in 
labor  ;3  after  labor  the  disorder  is  lessened.  The  greatest  danger  occurs 
when  the  cardiac  lesions  are  complex.  The  lesions  ranking  next  in 
point  of  peril  are  mitral ;  MacDonald  and  Porak  regard  mitral  stenosis 
as  presenting  the  greater,  mitral  insufficiency  the  less  risk.  Aortic  in- 
sufficiency is  extremely  dangerous  in  the  latter  months  of  pregnancy 
and  in  labor,  but,  provided  the  delivery  is  safely  accomplished,  the 
threatening  symptoms  disappear.  The  liability  to  abortion  or  to  prema- 
ture labor,  and  to  hemorrhage,  is  very  great  in  the  cardiopathic.  The 
placenta  is  in  some  cases  diseased. 

Hygiene.  Peter  states  that  a  woman  with  disease  of  the  heart  had 
better  not  marry.  If  she  is  married,  she  ought  not  to  be  a  mother.  If 
she  has  once  or  twice  become  a  mother  with  impunity,  she  ought  not 
to  have  another  pregnancy.  If  safely  delivered,  she  ought  not  to 
nurse  her  child. 

Medical  Treatment.  In  mitral  stenosis  the  tincture  of  strophanthus 
has  been  especially  commended  by  Edinburgh  obstetricians.4  In  gen- 
eral the  treatment  will  be  symptomatic  during  pregnancy,  especially 
regulating  the  various  secretions  and  directing  easily  digested  food. 

Obstetric  Treatment.  Berthiot  advises  auscultating  the  heart  of  a 
pregnant  woman,  so  that  if  disease  be  discovered  means  may  be  taken 
to  guard  against  its  accidents.  If  serious  accidents  arise  before  the 
child  is  viable,  it  is  justifiable  to  empty  the  uterus,  and  still  more  is 
this  action  right  if  the  period  of  viability  has  been  reached.  Wessner 
states  that  in  the  Berne  maternity  25  women  suffering  with  cardiac  dis- 
ease passed  through  95  parturitions,  and  only  one  died.  Winckel, 
quoting  these  statistics,  says  they  correspond  with  his  experience,  and 
rejects  artificial  interruption  of  pregnancy  in  the  treatment,  because  we 
cannot  be  sure  of  success,  and  because  "  this  proceeding  entails  injurious 
physical  excitement  and  local  irritations,  and  particularly  because  it  is 
not  certain  that  the  mother's  suffering  will  be  relieved  by  it."  When 
labor  occurs,  either  spontaneously  or  artificially,  art  should,  as  far  as 
can  be  done  without  violence,  replace  uterine  and  voluntary  effort  in 
effecting  delivery. 

Hart,5  in  the  management  of  the  third  stage  of  labor  in  a  patient 
suffering  from  mitral  stenosis,t  rejects  the  use  of  ergot,  and  regards  a 
free  discharge  of  blood  as  favorable.  If  the  circulation  becomes  em- 
barrassed, push  strophauthus  and  dry-cup  over  the  heart ;  bleed  the 
patient  from  the  arm  if  the  latter  fail. 

Disease  of  the  heart  does  not  necessarily  contra -indicate  anaesthesia 
in  labor.  MacDonald6  claims  that  chloroform  is  useful,  in  that  it  pre- 
vents bearing-down  efforts.  Vergely,  quoted  by  Dutertre,7  states  that 

i  Grossesse  et  Maladies  du  Cceur.  *  Quoted  by  Cbarpentler. 

s  Murray  estimates  that  in  22,000  labors,  of  282  deaths  independent  of  septic  disease,  16  were 
from  diseases  of  the  heart.    American  Journal  of  Obstetrics,  1889. 
4  Edinburgh  Obstetrical  Society's  Transactions,  vols.  xiii.  and  xiv. 

s  Edinburgh  Obstetrical  Society's  Transactions,  vol.  xiii.  6  Op.  cit. 

7  De  1'Emploi  du  Chloroforme  dans  les  Accouchements  Naturels,  1882. 


422  THE  PATHOLOGY  OF  PREGNANCY. 

cardiac  diseases  do  not  forbid  the  use  of  an  anaesthetic  in  labor,  and 
chloroform  acts  as  a  sedative  to  the  heart  in  these  affections,  and  may 
be  given  prudently. 

Dr.  J.  C.  Webster,  of  Edinburgh,1  advises  in  serious  cases  of  cardiac  disease? 
especially  mitral,  chloroform  in  labor  and  delivery  with  the  forceps ;  he  states 
that  occasional  hypodermatics  of  ether  may  be  needed.  He  especially  recom- 
mends the  nitrite  of  amyl,  four  or  five  minims  inhaled  at  a  time,  and  refers  to 
its  having  been  first  given  by  Fraser  Wright  in  a  case  of  labor  complicated  by 
heart  disease.  "  Its  action  is  to  lessen  the  strain  on  the  heart  through  the  dila- 
tation which  it  causes  in  the  small  peripheral  vessels  throughout  the  body,  either 
from  paralysis  of  the  muscular  flares  of  the  arterioles  or  of  the  vasomotor 
ganglia  in  them.  Soon  after  its  administration  (from  twenty  to  thirty  seconds) 
its  effects  are  seen." 

CHRONIC  INFECTIOUS  DISEASES.  Phthisis.  The  statistics2  of  the 
late  Dr.  Austin  Flint,  as  well  as  the  investigations  of  Gaulard,3  show 
that  a  large  per  cent,  of  women  become  phthisical  during  pregnancy. 
The  former  has  stated  that  in  11.5  per  cent  of  women  under  forty 
years  of  age  who  are  affected  by  phthisis,  the  disease  is  developed  dur- 
ing gestation,  and  in  13-f^-  per  cent,  soon  after  confinement.  According 
to  Gaulard,  the  puerperal  state  and  lactation  determine  phthisis  in  at 
least  three-fourths  of  the  cases  of  the  disease  in  women.  The  late  Dr. 
George  B.  Wood4  taught  that  the  occurrence  of  pregnancy  undoubtedly, 
in  many  instances,  arrests  for  a  time  the  progress  of  the  disease,  and 
that  lactation  appears  to  exercise  a  favorable  influence  over  it.  He 
even  held  that  the  disease  might  be  kept  at  bay  for  many  years  by 
childbearing  and  nursing,  so  that  occasionally  the  predisposition  ap- 
peared to  be  overcome.  Dr.  Flint's  statistics  show  that  in  the  majority 
of  cases  pregnancy  does  not  show  an  unfavorable  influence.  James5 
has  maintained  that  pregnancy  has  a  favorable  effect  upon  phthisis, 
but  that  labor  and  lactation  are  undoubtedly  injurious.  But,  as  Stoltz 
has  said,6  it  is  not  probable  that  an  exhausting  function  which  involves 
the  entire  economy  will  spare  a  diseased  organ.  In  many  cases  the 
phthisical  succumb  some  weeks  or  some  days  after  premature  de- 
livery. The  cases  are  exceptional  in  which  the  health  seems  to  be, 
or  is  temporarily,  benefited  by  pregnancy.  "  The  children  born  of 
phthisical  mothers  are  usually  feeble,  often  at  first  become  scrofulous, 
and  subsequently  tuberculous."7 

In  a  few  cases  the  tubercle-bacillus  has  been  found  in  the  placenta  and  in  the 
foetus  of  the  mother  suffering  with  pulmonary  tuberculosis ;  this  has  occurred 
not  only  in  the  human  subject,  but  also  in  the  progeny  of  some  of  the  inferior 
animals,  e.  g.,  the  calf. 

Winckel  quotes  the  case  reported  by  Charriere,  1873,  of  a  child  born  of  a 
phthisical  mother,  dying  the  third  day  of  general  tuberculosis. 

Syphilis.  Fournier  regards  pregnancy  as  a  complication  of  syphilis  :8 
"  It  complicates  it  by  adding  to  its  own  peculiar  anaemia,  its  debilitat- 
ing influence,  its  disposition  to  neuroses,  its  disorders  of  nutrition,  etc." 

1  The  Hospital.  June,  1894.  2  Phthisis. 

3  Quoted  by  Charpentier.  *  Treatise  on  the  Practice  of  Medicine. 

5  Edinburgh  Medical  Journal,  1886. 

c  Nouveau  Dictionnaire  de  Medecine  et  de  Chimrgie  Pratiques,  tome  xvii.  "  Gaulard. 

8  Lemons  Cliniques  sur  la  Syphilis,  second  edition,  1881. 


CHRONIC  AND  ACUTE  DISEASES  IN  PREGNANCY.  423 

Abortion  or  premature  labor  is  a  very  common  consequence  of  syphilis. 
Thus  out  of  414  pregnant  women  at  Lourcine,  only  260  arrived  at 
term.  Abortion  from  syphilis  is  not  produced  alone  in  coincidence 
with  contemporary  syphilitic  manifestations;1  it  often,  very  often,  occurs 
independent  of  all  actual  accident,  as  an  isolated  phenomenon,  as  the 
sole  expression  of  the  diathesis. 

The  secondary  stage  of  the  disease  is  that  which  furnishes  the  greatest 
liability  to  abortion ;  from  the  fourth  month  to  the  end  of  the  second 
year  is,  according  to  Fournier,  the  time  when  syphilitic  abortions  most 
frequently  occur.  Thus,  a  woman  who,  being  syphilitic,  becomes  preg- 
nant, is  more  liable  to  abort  than  one  who,  being  pregnant,  becomes 
syphilitic.  If  the  contagion  is  commuicated  at  the  time  of  the  impreg- 
nation— that  is,  the  fecundating  is  the  infecting  coition — there  is  great 
danger  of  abortion  ;  but  if  the  poison  is  received  after  the  fourth  month 
the  danger  is  slight,  and  almost  nothing  if  the  infection  occurs  toward 
the  close  of  pregnancy.  According  to  excellent  authorities,  the  father 
may  beget  syphilitic  offspring  without  the  mother  being  affected. 
Again,  it  is  held  by  some,  Fournier  among  the  number,  that  the  dis- 
ease may  be  transmitted  by  the  foetus  to  the  mother.  The  antisyphi- 
litic  treatment  is  indicated  in  pregnancy  if  the  father  be  syphilitic,  even 
though  the  mother  has  had  no  manifestations  of  the  disease,  but  still 
more  if  she  has  such  manifestations. 

Pneumonia.  This  is  a  much  more  frequent  disease  of  the  male  than 
of  the  female,  but  in  the  latter  has  a  one-third  greater  mortality.  It  is 
not  frequent  in  pregnancy.  Devilliers  and  Matton,2  however,  regard 
the  increase  of  fibrin  in  the  blood  as  predisposing  to  it,  but  this  could 
only  be  the  case  in  the  latter  part  of  pregnancy.  The  disease  is  one  of 
great  gravity  both  for  the  mother  and  for  the  child.  The  high  maternal 
temperature,  want  of  proper  oxygenation  of  the  blood,  and  a  less  sup- 
ply of  blood  to  the  placenta  explain  the  dangers  to  the  fcetus.  A 
greater  mass  of  blood  in  the  pregnant  woman  to  be  purified,  and  much 
lessened  space  for  its  purification,  indicate  the  danger  of  the  disease  to 
the  mother,  the  lungs  made  hypersemic  in  the  effort  of  the  right  ven- 
tricle to  overcome  the  difficulty,  and  possibly  oedema  resulting  from  the 
hypersemia. 

Pregnancy  is  more  liable  to  interruption  the  further  it  is  advanced 
when  the  disease  occurs.  If  abortion  or  premature  labor  occur,  one- 
half  the  mothers  die ;  but  if  the  pregnancy  continue,  only  one  in  be- 
tween five  and  six  dies.  Martin3  confirms  the  statement  of  Ricau,4 
derived  from  statistics,  that  a  pneumonia  before  the  one  hundred  and 
eightieth  day  is  least  dangerous  for  the  mother  and  the  fcetus.  Ricau 
found  that  in  28  cases  of  pneumonia  in  pregnant  women,  23  recovered, 
6  with,  17  without  miscarriage  ;  of  15  others  with  pneumonia  after  the 
one  hundred  and  eightieth  day,  only  8  recovered,  5  with,  3  without 
miscarriage,  while  7  died. 

Chatelain's  statistics,5  quoted  by  Lepine,  include  39  cas.es.  In  10 
abortion  occurred,  and  in  9  premature  labor  was  induced;  of  the  19, 

1  Fournier.  2  DG  la  Puerperalite,  par  le  Dr.  Raymond. 

3  Zeitschrift  fur  Geburtshiilfe  und  Gynakologie,  1885.  <  Paris  Thesis,  1874. 

6  Nouveau  Dictionnaire  de  MSdecine  et  de  Chirurgie  Pratiques,  tome  xxviii. 


424  THE  PATHOLOGY  OF  PREGNANCY. 

10  died,  and  of  the  remaining  20,  10  also  died,  the  entire  mortality 
being  nearly  50  per  cent.  Kicau  states  that  when  pneumonia  occurs  in 
the  last  three  months  of  pregnancy,  half  the  patients  die,  while  death 
is  the  exception  if  the  disease  occur  in  the  first  six  months. 

Some  have  advocated  the  induction  of  abortion  or  of  premature 
labor  in  the  treatment  of  grave  cases  of  pneumonia.  Upon  theoretical 
grounds  such  treatment  has  been  condemned.  The  evacuation  of  the 
uterus,  as  Kleinwachter  has  said,  suddenly  reduces  the  intra-abdominal 
pressure,  but  even  if  the  diaphragm  be  immediately  given  greater 
range,  which  he  doubts,  with  every  inspiration  there  is  a  greater  flow  of 
blood  to  the  numerous  venous  branches  of  the  thorax,  and  also  perma- 
nent increase  of  pressure  in  the  pulmonary  vessels,  and  an  increased 
load  of  venous  blood  is  thrown  upon  the  pulmonary  arteries  when  a 
considerable  portion  of  the  lung  is  unfit  to  decarbonize  the  blood. 
Charpentier  believes  that  the  induction  of  labor  ought  not  to  be  abso- 
lutely rejected,  but  reserved  for  special  cases ;  but  Spiegelberg  absolutely 
rejects  it  in  all  cases.1 

Pleurisy.  This  disease  usually  terminates  favorably,  and  does  not 
disturb  the  pregnancy.  But  if  bronchitis  be  associated  with  it,  or  if 
the  pleurisy  be  double,  abortion  or  premature  labor  may  result.  Never- 
theless, in  all  cases  pleurisy  is  a  more  serious  disease  in  the  pregnant 
than  in  the  non-pregnant,  because  the  effusion  for  the  time  lessens  the 
pulmonary  capacity,  which  is,  of  course,  a  greater  evil  to  the  former 
than  to  the  latter.  Thoracentesis  has  been  done  in  pregnancy  without 
any  injurious  effect  upon  it. 

Jaundice.  Jaundice  may  occur  in  pregnancy  in  either  one  of  two 
forms,  simple  or  malignant.  The  first,  observed  in  the  later  months,  is 
attributed  by  Frerichs2  to  pressure  of  the  enlarged  uterus,  or  of  the 
colon  distended  by  fecal  matter,  upon  the  bile-duct.  Bedford3  suggests 
that  jaundice  in  pregnancy  may  sometimes  be  in  part  due  to  strong 
mental  emotions.  The  second  form  of  the  disease,  malignant  jaundice, 
may  appear  much  earlier  than  the  simple  form,  and  is  dependent  upon 
very  serious  structural  change  in  the  liver. 

Peter4  explains  the  jaundice  of  pregnancy  as  resulting  from  an  exaggeration 
of  the  physiological  hypersemia  of  the  liver.  According  to  Tarnier,  the  liver  of 
a  woman  dying  in  pregnancy  or  in  childbed  is  enlarged,  and  there  is  fatty  infil- 
tration between  the  cells.  It  is  an  organ  for  the  elimination  of  ternary  com- 
pounds, and  its  work  is  greatly  increased  in  pregnancy.  When  the  elimination 
is  deficient  infiltration  occurs.  "  But,  apart  from  the  benign,  there  is  a  malig- 
nant jaundice  of  pregnant  women.  Some  women  have  a  benign  jaundice  up  to 
a  certain  time,  are  suddenly  attacked  by  accidents,  which  rapidly  end  in  death, 
and  which  characterize  malignant  jaundice.  This  jaundice  is  the  poisoning  of 
the  organism  by  the  accumulation  in  the  blood  of  bile  materials  uneliminated 
by  the  diseased  liver,  a  poisoning  which  I  call  cholemic  typhisation." 

Acute  yellow  atrophy  of  the  liver,  which  is  present  in  malignant 
jaundice,  is  supposed  to  result  from  a  constitutional  affection.  Buhl 
regards  the  hepatic  disease  as  one  of  the  evidences  of  impaired  nutrition 

1  "  Fischl  has  compared  the  21  cases  collected  by  Gusserow  in  which  premature  labor  was  in- 
duced on  account  of  pulmonary  disease,  with  21  others  in  which  an  expectant  treatment  was  pur- 
sued ;  of  the  former  15  women  died,  of  the  latter  only  3  "—Spiegelberg. 

8  Clinical  Treatise  on  Diseases  of  the  Liver.  «  Obstetrics  4  Clin.  M6dicale. 


CHRONIC  AND  ACUTE  DISEASES  IN  PREGNANCY.  425 

of  the  entire  organism.  Wunderlicli  considers  the  destructive  process 
in  the  liver  to  be  caused  by  an  acute  pernicious  constitutional  affection. 
Duncan1  states  that  the  disease  is  not  seen  oftener  than  once  in  10,000. 
Its  greater  relative  frequency  in  pregnant  women,  and  its  progressing 
so  rapidly,  have  been  attributed  to  the  fact  that  pregnancy  predisposes 
to  parenchymatous  degeneration  of  the  glandular  organs,  especially  of 
the  liver  and  of  the  kidneys. 

The  statistics  of  Frerichs  show  not  only  that  females  are  more  liable 
to  the  disease  than  males — in  31  cases  22  were  females — but  also  that 
pregnancy  was  a  predisposing  cause,  one-half  of  those  attacked  being 
pregnant.  Thiesfelder's  statistics2  show  that  in  88  cases  of  acute  yellow 
atrophy  of  the  liver  in  women  the  disease  appeared  in  30  during  preg- 
nancy and  3  in  the  lying-in.  Spaeth,  finding  only  two  cases  in  33,000 
pregnant  women,  concluded  that  the  disease  was  extremely  rare.  But 
Ollivier3  has  said  in  reply  that  women  suffering  from  jaundice  in  preg- 
nancy would  be  received  into  general  hospitals,  and  not  enter  maternities, 
and  that  recent  observations  have  shown  that  grave  jaundice  in  preg- 
nant women  is  not  so  rare  as  those  statistics  indicate. 

The  disease  has  occurred  as  an  epidemic,  and  is  then  peculiarly  fatal. 
In  nearly  two-thirds  of  the  cases  abortion  or  premature  labor  occurs. 
Dr.  J.  W.  Underbill4  regards  it  "as  doubtful  whether  a  well-authenti- 
cated case  of  malignant  jaundice  occurring  in  gestation  has  recovered." 
On  the  other  hand,  Charpentier  presents  a  table  of  68  cases ;  42  of  these 
patients  miscarried,  and  of  these  30  died  and  12  recovered,  while  the 
remaining  26  were  delivered  at  full  term. 

Premonitory  symptoms  are  observed  in  one-half  the  cases.  They 
may  precede  the  serious  manifestations  of  the  disease  two  or  three 
weeks,  but  usually  only  three  to  five  days;  they  generally  indicate 
acute  catarrh  of  the  stomach  and  bowels.  The  jaundice  is  slight,  and, 
Duncan  states,  may  be  absent.  Great  nervous  excitement,  generally 
violent  pain  in  the  head,  delirium,  and  convulsions  are  succeeded  by 
prostration  and  stupor,  and  then  a  coma,  which  ends  in  death.  Abor- 
tion or  premature  labor  usually  precedes  death ;  in  some  cases  the  disease 
is  so  rapidly  fatal  that  the  uterus  does  not  discharge  its  contents. 

Treatment.  The  mild  form  requires  little  or  no  medication.  It  may 
be  advisable  to  give  laxatives  and  direct  an  occasional  warm  bath ;  in 
some  cases  diuretics  to  assist  the  eliminating  action  of  the  kidneys  will 
be  useful.  In  the  grave  form  of  the  disease  Duncan  suggests  emptying 
the  uterus  as  the  only  thing  in  the  way  of  treatment.  But  Charpentier, 
in  view  of  the  disastrous  results  which  have  been  seen  to  follow  abor- 
tion, regards  the  induction  of  abortion,  or  even  of  premature  labor,  as 
out  of  the  question.  Cazeaux  advises  that  the  woman  change  her  resi- 
dence. But,  if  already  attacked,  this  change  could  do  no  good. 

Chorea.  This  affection,  much  more  frequent  in  the  female  than  in 
the  male — the  proportion,  according  to  Simon,  being  three  to  one — is 
seldom  in  pregnancy.  In  1868  Barnes5  could  find  but  56  cases  of 
chorea  as  a  complication  of  pregnancy.  Fehling,  in  1874,  found  68  cases. 

1  Clinical  Lectures  on  Diseases  of  Women. 

2  Ziemssen's  Handbuch.  3  Archives  G6n6rales,  1873. 

4  Transactions  of  the  American  Gynecological  Society,  vol.  vi. 

5  London  Obstetrical  Society's  Transactions,  vol.  x. 


426  THE  PATHOLOGY  OF  PREGNANCY. 

Charpentier  remarks  that  in  1600  deliveries  at  the  Cliniqtie  there  were 
but  two  cases  of  chorea,  but  recently  he  has  seen  a  third,  in  which,  how- 
ever, the  disease  appeared  after  delivery.  Winckel  states  that  he  has 
seen  but  one  case.  The  liability  to  the  disease  is  greater  in  first  than 
in  other  pregnancies ;  the  larger  number  of  those  affected  are  between 
twenty  aud  twenty-five  years  of  age.  Chorea  may  occur  in  a  first  and 
not  in  a  subsequent  pregnancy,  or  it  may  be  manifested  in  several  preg- 
nancies. Previous  attacks  of  the  disease,  as  in  childhood,  create  a  lia- 
bility to  it.  It  usually  begins  in  the  first  half  of  gestation  and  con- 
tinues until  the  end  of  the  pregnancy ;  in  rare  instances  it  remains 
through  the  puerperal  state. 

Barnes  considers  the  disease  is  chiefly  dependent  upon  an  altered  con- 
dition of  the  blood,  but  states  that  in  addition  to  this  there  is  an  ante- 
cedent condition,  a  predisposing  cause,  the  nature  of  which  is  a  matter 
of  speculation.  Spiegelberg  regarded  the  cause  of  chorea,  except  in 
cases  where  a  central  lesion  exists,  and  others  of  an  hereditary  charac- 
ter, as  imperfectly  understood  :  "  Occasionally  it  is  found  in  connection 
with  disease  of  the  heart  and  rheumatism,  and  possibly  some  of  the  central 
lesions  may  be  connected  with  embolic  processes  consequent  upon  cardiac 
disease.  In  many  cases  no  clearly  defined  cause  can  be  found,  and  these 
may  be  considered  reflex  neuroses,  which  may  be  developed  under  the 
influence  of  predisposition,  insufficient  nutrition  of  nerve  centres  from 
impoverished  blood,  and  the  peripheral  irritation  from  the  sexual  organs." 

Psychical  causes — such  as  fear,  sorrow,  and  anxiety — often  have  a 
marked  influence  in  determining  an  outbreak  of  the  disease,  but  Trous- 
seau has  recorded  a  case  in  which  chorea  ceased  with  the  occurrence  of 
pregnancy.1  Chorea  may  begin  gradually  or  suddenly.  In  most  cases 
the  movements  are  bilateral,  and  in  almost  all  they  cease  during  sleep. 
The  mortality  of  chorea  in  children  is,  according  to  S6e,  5.7  per  cent., 
while  the  statistics  of  Wenzelshow  a  mortality  of  27.3  per  cent,  in  preg- 
nant women.  Spiegelberg  found  in  84  cases  23  deaths.  Death  occurs 
from  the  complications  rather  than  from  the  disease  itself.  Chorea  in 
many  cases  causes  abortion  or  premature  labor. 

Treatment.  The  medical  treatment  includes  tonics,  the  alkaline 
bromides,  opium,  hypodermatic  morphine,  and  chloral.  Wade2  nar- 
rates a  case  in  which  digital  dilatation  of  the  os  uteri  was  successful  in 
curing  the  patient,  the  pregnancy  being  uninterrupted.  If  the  foetus  be 
viable,  and  the  usual  means  for  the  relief  of  the  disease  have  been  faith- 
fully tried  without  benefit,  the  choreic  movements  are  violent,  and  the 
patient's  strength  is  failing,  the  induction  of  labor  is  generally  consid- 
ered by  obstetricians  advisable.  But  whether  cases  occur  in  which 
abortion  is  proper  is  still  an  unsettled  question. 

Hysteria.  The  Father  of  Medicine  advised  marriage  as  the  remedy 
for  hysteria ;  the  value  of  this  treatment  has  not  been  confirmed  by 
modern  observation.  In  regard  to  the  influence  of  pregnancy  upon 
hysteria,  no  absolute  rule  can  be  given,  but  certainly  it  does  not  cure  it. 
In  the  earlier  months  the  hysterical  attacks  are  usually  more  frequent 
and  severe,  while  in  the  later  months  the  opposite  is  often  seen.  Ray- 

1  Bulletin  Gen.  de  Therap.,  1846. 

2  London  Obstetrical  Society's  Transactions,  vol.  xxii. 


CHRONIC  AND  ACUTE  DISEASES  IN  PREGNANCY.  427 

mond1  states  that  the  hysterical  may  pass  through  labor  without  suffer- 
ing as  a  common  fact  which  has  been  mentioned  by  a  number  of  authors. 
Epilepsy.  In  some  cases  of  epilepsy  the  convulsive  attacks  during 
pregnancy  are  rarer,  but  after  the  pregnancy  ends  they  resume  their 
former  frequency ;  in  others  no  change  is  observed,  while  in  still  others 
the  attacks  are  more  severe.  In  one  case  under  my  own  care  the  attacks 
were  less  severe  and  frequent  during  the  pregnancy,  but  after  puer- 
peral convalescence  they  resumed  their  former  frequency  and  severity. 

"  Obstetricans  found  that  the  offspring  were  most  frequently  diseased  when  the 
mother  was  epileptic,  rather  than  the  father.  This  is  readily  intelligible  when 
we  remember  that  the  ovum  contains  an  immensely  larger  amount  of  substance 
than  the  spermatozoon,  and  can  therefore  be  more  frequently  infected  by  mi- 
crobes and  can  contain  a  larger  number  of  them." — Weissman's  Significance  of 
Sexual  Reproduction. 

ACUTE  INFECTIOUS  DISEASES.  The  premature  interruption  of  preg- 
nancy is  not  uncommon  in  the  severer  of  these  diseases.  This  interrup- 
tion may  be,  primarily,  according  to  Kalteubach,  in  consequence  of  the 
fever,  irritation  of  the  contraction  centres  through  the  blood  affected  by 
the  fever,  or,  as  Vinay  maintains,  from  the  toxines  elaborated  by  the 
infectious  agents,  these  toxiues  exciting  uterine  contractions. 

The  death  of  the  foetus  may  result  from  the  infection  passing  over  to 
it  from  the  mother,  as  has  been  observed  in  some  cases  of  measles, 
variola,  scarlatina,  etc.  The  high  temperature  of  the  foatus  may  destroy 
its  life ;  experiments  seem  to  show  that  sudden  elevations  of  tempera- 
ture are  dangerous,  while  if  the  increase  be  gradual  the  foetus  may  be 
unaffected  even  by  a  prolonged  high  temperature.  Further,  foetal  death 
may  be  the  result  of  asphyxia  consequent  upon  the  condition  of  the 
mother.  Finally,  decidual  hemorrhages,  observed  by  Slavjansky  in 
cholera,  may  be  the  cause  of  foetal  death. 

Typhoid  Fever.  Vinay  asserts  that  gestation  is  interrupted  in  65  per 
cent.  Charpentier  gives  a  table  including  322  cases,  collected  from 
various  authors;  in  182  abortion  or  premature  labor  occurred.  He 
holds  that  if  premature  labor  occurs  the  child  may  be  still-born,  or  if 
born  alive  it  is  feeble,  and  death  may  follow,  preceded  by  the  symptoms 
of  typhoid  fever.2 

Murchison3  stated  that,  "according  to  Rokitansky  and  Niemeyer, 
pregnancy  confers  almost  entire  immunity  from  enteric  fever;  but  the 
correctness  of  this  opinion  has  been  denied  by  Forget,  Jenner,  Griesiu- 
ger,  and  others.  I  have  met  wi,th  many  instances  of  pregnant  females 
attacked  by  the  disease."  He  regarded  pregnancy  as  a  less  serious 
complication  than  is  commonly  supposed.  The  women  generally  mis- 
carry or  have  premature  labor,  but  recovery  takes  place  in  the  great 
majority.  Savidan4  has  collected  31  cases  of  typhoid  fever  in  preg- 
nancy, with  five  deaths.  One  of  the  fatal  cases  was  complicated  with 

1  Op.  cit. 

2  Jaggard,  American  Journal  of  Obstetrics,  1889,  gives  as  the  causes  of  interruption  of  pregnancy 
from  typhoid  fever,  these  :  1.  Elevation  of  maternal  temperature,  causing  death  of  the  Icetus  by 
insolation,  or  its  premature  expulsion  by  thermic  irritation  of  the  uterine  musculature.    2.  Hemor- 
rhagic  endometritis.    3.  Depression  of  maternal  blood-pressure  with  asphyxiation  of  the  child. 
4.  It  has  been  proved  that  the  bacillus  of  typhoid  fever  may  pass  into  the  blood  of  the  foetus. 

3  Continued  Fevers.    Third  edition,  1886.  «  Paris  Thesis,  1884. 


428  THE  PATHOLOGY  OF  PREGNANCY. 

the  obstinate  vomiting  of  pregnancy,  and  another  with,  probably,  acute 
yellow  atrophy  of  the  liver.  In  typhus  fever  only  about  one-half  abort, 
but  the  majority  even  of  these  recover.  Murchison's  statistics  from 
1862  to  1870  include  107  pregnant  women  suffering  from  typhus  under 
his  care;  49  aborted,  and  nine  of  these  died. 

Cold  baths1  and  antipyrine  have  each  been  used  in  the  treatment  of 
typhoid  fever  in  pregnant  women,  and  without  any  injurious  effect. 

Yellow  Fever.  Millot2  notes  the  fact  that  when  yellow  fever  appeared 
at  Livourne,  in  1804,  the  only  time  it  has  been  seen  in  Italy,  all  preg- 
nant women  perished  of  black  vomit.  In  general,  yellow  fever  is  one 
of  the  most  dangerous  of  acute  diseases  in  pregnancy. 

I  am  indebted  to  my  friend,  the  late  Dr.  S.  M.  Bemiss,3  of  New 
Orleans,  for  the  following  conclusions  as  to  the  relations  of  yellow  fever 
and  pregnancy. 

1.  Pregnancy  is  altogether  indifferent  as  it  regards  liabifity  to  attacks  of  yellow 
fever  after  exposure.     My  observations  on  this  point  are  sufficient  to  justify  an 
opinion  that  pregnant  women  are  neither  more  nor  less  liable  to  the  disease  than 
the  non-gravid. 

2.  When  pregnant  women  are  attacked  by  yellow  fever  the  danger  of  fatal 
results  is  so  much  increased  that  one  might  almost  say  it  is  exceptional  for 
recovery  to  occur.     But  this  strong  statement  of  danger  ascribable  to  pregnancy 
is  applicable  to  other  severe  epidemic  visitations,  and  includes  all  cases  treated 
in  hospitals  and  in  the  various  social  conditions  of  private  practice.     In  recall- 
ing the  events  which  have  occurred  in  the  ordinary  run  of  private  practice  in 
the  best  districts  of  this  city,  I  can  safely  say  that  I  have  not  lost  over  thirty- 
three  per  cent,  of  pregnant  patients.     This  is  something  more  than  double  the 
percentage    of   mortality  of   the    non-pregnant.     We   may,   therefore,   safely 
postulate  the  danger  to  the  pregnant  woman  as  being  double  that  of  the  non- 
gravid. 

3.  The  dangers  attending  pregnancy  are  to  be  ascribed  to  the  great  liability  to 
abortion  and  death  from  hemorrhage.     Perhaps  liability  to  suppression  of  renal 
secretion  and  death  from  uraemia  may  also  be  greater.    Embolism  and  thrombosis 
are  quite  common  events  in  protracted  cases  of  yellow  fever,  but  I  have  no  recol- 
lection of  such  accidents  in  any  pregnant  woman  in  my  practice. 

4.  The  pregnant  woman,  being  attacked  by  yellow  fever  and  recovering  without 
miscarriage,  immunity  from  future  attacks  is  conferred  upon  the  offspring  con- 
tained in  the  womb  during  the  attack.     This  is  an  extremely  interesting  proposi- 
tion.    I  regret  that  I  have  only  three  accurate  observations  which  support  it,  but 
I  believe  that  further  investigations  will  confirm  its  truth. 

5.  The  recently  delivered  woman  is  more  liable  to  be  attacked  by  yellow  fever 
than  one  differently  circumstanced,  both  being  equally  exposed.     I  cannot  estab- 
lish this  proposition  by  any  indisputable  facts.     It  is  a  current  belief  among 
those  who  have  observed  much  yellow  fever  that  traumatic  conditions  invite 
attacks  of  yellow  fever.     My  own  observations  support  this  opinion,  and  more 
especially  as  it  relates  to  the  parturient  woman. 

6.  The  recently  delivered  woman,  being  attacked  by  yellow  fever,  encounters 
an  increased  degree  of  danger  nearly  or  quite  equal  to  that  of  the  pregnant 
woman. 

Intermittent  Fever.  It  is  a  mistake  made  by  some  to  regard  preg- 
nancy as  furnishing  any  immunity  from  malaria.  The  opposite  opinion — 
that  is,  that  the  condition  creates  an  increased  liability  to  the  occurrence 
of  its  manifestations — is  more  probable. 

i  Lyon  M6dical.  1887.  *  Op.  cit. 

3  Dr.  Bemiss,  as  will  be  at  once  admitted  by  all  who  knew  this  excellent  man  and  wise  physi- 
cian, was  eminently  careful  and  conscientious  in  his  investigations,  and  hence  his  conclusions 
may  be  readily  accepted. 


CHRONIC  AND  ACUTE  DISEASES  IN  PREGNANCY.  429 

Torti,1  Doublet,2  and  Osiander3  mentioned  the  occurrence  of  inter- 
mittent fever  in 'pregnant  women;  Doublet  spoke  of  it  as  quite  fre- 
quent. 

Goth's  statistics,  quoted  by  Charpentier,  show  that  46  of  881  preg- 
nant women  suffered  from  malarial  attacks ;  of  the  46,  5  miscarried, 
14  had  premature  labor,  and  in  only  27  the  pregnancy  was  uninter- 
rupted. 

Bonfils4  has  collected  140  cases,  many  of  them  unpublished.  In  very 
many  premature  labor  occurred,  but  in  very  few  abortion.  He  found 
that  chronic  malarial  poisoning  manifested  its  influence,  especially  by 
the  death  of  the  foetus  and  by  its  insufficient  development.  In  regard 
to  the  last  point,  the  weight  of  the  foetus  was  found  to  be  500  grammes 
under  the  normal,  and  its  length  ten  centimetres  less  than  the  usual 
length. 

One  of  the  curious5  facts  asserted  by  different  observers  is  that  the 
foetus  may  suffer  with  intermittent  attacks,  occurring  at  the  same  time 
with  those  of  the  mother;  in  some  instances  the  attacks  have  continued 
after  birth,  and  in  all  the  child  had  at  birth  an  enlarged  spleen. 

Goodell  and  Harris6  have  "  related  cases  in  which  the  foetus  seemed 
to  have  been  affected  by  the  malarial  poison,  the  mothers  stating  that 
they  were  aware  of  periodical  convulsive  movements  of  the  children, 
their  own  system  being  apparently  unaffected." 

In  nine  cases  the  foetus  was  thought  to  be  affected  by  malarial  poison- 
ing while  in  the  uterus,  according  to  Bonfils. 

The  treatment  of  intermittent  fever  in  pregnancy  is  the  same,  so  far 
as  the  administration  of  antiperiodics  is  concerned,  as  if  the  patient 
were  not  pregnant.  There  need  be  no  hesitation  in  giving  quinine,  for 
example,  and  giving  it  freely,  unless  some  idiosyncrasy  forbids  its  use. 
The  late  Dr.  Henry  F.  Campbell  referred7  to  "  the  thousands  of  preg- 
nant women  who  daily  use  the  drug  to  prevent  or  break  the  force  of 
paroxysms  of  fever,"  without  its  ever  entering  the  mind  of  patient  or 
of  physician  that  it  has  any  influence  in  interrupting  pregnancy.  If 
abortion  or  premature  labor  follow  the  use  of  quinine  in  malarial  fever, 
the  result  is,  as  a  rule,  that  of  the  disease,  not  of  the  medicine. 

Cholera.  Pregnancy  neither  exempts  from  nor  predisposes  to  cholera. 
Kleinwachter  states  that  this  more  frequently  than  any  other  epidemic 
disease  attacks  the  pregnant  woman,  especially  in  the  latter  months. 
Abortion  or  premature  labor  is  caused  in  about  60  per  cent.  Accord- 
ing to  some,  the  foetus,  too,  may  have  cholera.  The  death  of  the  foetus, 
if  not  due  to  the  cause  just  mentioned,  may  be  attributed  to  the  cramps 
and  spasmodic  movements  of  the  abdominal  muscles  of  the  mother, 
producing  mechanical  pressure;  to  the  absolute  diet  to  which  she  is 

1  Therapeutice  Specialis  ad  Febres  Perniciosas.    Venice,  1709. 

2  Nouvelles  Recherches  de  la  Fi&vre  Puerperale.    Paris,  1791. 

3  Beobachtungen  Abhandlung  und  Nachrichten.    Tubingen,  1787. 
«  Paris  Thesis,  1885. 

6  In  a  paper  by  Dr.  R.  W.  Felkin,  Edinburgh  Obstetrical  Society's  Transactions,  vol.  xiv.,  the 
author  states  that  it  has  long  been  recognized  that  a  foetus  in  utero  can  suffer  from  a  paroxysm  of 
malarial  fever,  and  ague-cake  in  the  foetus  is  perfectly  familiar  to  those  \\ho  have  practised  in 
tropical  countries.  Dr.  Felkin  further  adduces  two  cases  to  show  that  the  malarial  as  the  syphilitic 
poisoning  may  be  communicated  from  the  father,  the  mother  being  entirely  free  from  any  malaria 
manifestations  both  before  and  after  the  conception  of  the  child. 

6  American  Journal  of  Obstetrics,  vol.  ii. 
Transactions  of  American  Gynecological  Society,  vol.  v. 


430  THE  PA  THOL  OGY  OF  PREGNA SCY. 

subjected ;  to  the  loss  of  the  serous  portion  of  the  blood,  making  it 
unfit  for  nutrition  ;  some  regard  asphyxia  as  the  chief,  if  not  the  sole, 
cause  of  the  death  of  the  foetus ;  Kleinwiichter  conjoins  with  it  the 
great  loss  of  the  water  of  the  blood,  and  the  lessened  blood-pressure. 
The  prognosis  for  the  mother  is  also  bad,  but  the  pregnant  condition 
furnishes  no  special  therapeutic  indications. 

In  the  statistics1  of  Queirel,  embracing  67  cases  of  cholera  in  preg- 
nant women,  39  died  and  28  recovered.  If  abortion  or  premature 
labor  occurred,  the  mortality  was  about  66  per  cent. ;  but  if  the  preg- 
nancy was  not  interrupted,  the  mortality  was  50  per  cent. 

Gaillard,  October  1,  1892,  regards2  pregnancy  as  a  very  grave  complication  of 
cholera.  "A  pregnant  woman  is  particularly  unauited  to  resist  invasion  of 
germs.  She  is  equally  unfit  to  bear  an  operation."  Hence,  even  induction  of 
premature  labor  means,  in  Dr.  Gaillard's  opinion,  the  certain  death  of  the 
mother  in  order  to  give  a  very  small  chance  of  life  to  the  child. 

Tipjahoff,3  1892,  had  7  cases  of  cholera  in  pregnant  women — in  all  pregnancy 
was  interrupted,  and  only  one  survived. 

Variola.  This  is  the  most  grave  of  acute  infectious  diseases  which 
may  attack  the  pregnant  woman.  According  to  Curschmau,4  her  con- 
dition causes  a  certain  predisposition  to  the  disease,  and  increases  its 
malignancy.  The  danger  to  mother  and  foetus  is  very  slight  in  vario- 
loid,  but  in  variola,  if  confluent,  abortion  or  premature  labor  usually 
occurs,  and  is  followed  by  the  death  of  the  mother.  If  a  pregnant 
woman  has  the  disease,  the  rule  is  that  her  foetus  is  also  affected,  and  it 
may  pass  through  all  the  stages  of  the  disease  in  the  uterus ;  in  some 
instances  it  is  born  with  the  disease,  while  in  others  it  is  born  appar- 
ently well,  but  is  attacked  soon  after  birth.  In  rare  cases  an  appa- 
rently healthy  mother  gives  birth  to  a  child  having  variola ;  Cursch- 
man  explains  such  cases  by  the  hypothesis  that  the  mother  had  "  variola 
sine  exanthemate,"  and  thus  infected  the  child.  When  mother  and 
foetus  are  both  affected,  the  disease  begins  earlier  in  the  former,  the  latter 
not  being  attacked  until  the  suppurative  stage  has  begun  in  the  mother. 
The  disease  may  appear  in  the  foetus  as  early  as  the  fourth  month.  In 
twin  pregnancy,  one  foetus  may  be  born  with  the  disease,  while  the 
other  is  entirely  free  from  it. 

When  the  infection  takes  place  early  in  pregnancy,  the  dead  foetus  is 
usually  expelled  in  three  or  four  days,  but  it  may  remain  for  as  many 
weeks.  In  some  cases  the  disease  is  so  severe  that  the  woman  dies  very 
early  without  aborting  or  having  premature  labor.  The  further  ad- 
vanced a  woman  is  in  pregnancy,  the  greater  the  liability  to  the  disease, 
and  the  greater  its  gravity. 

Vaccination  of  the  pregnant  woman,  if  she  has  not  been  recently 
vaccinated,  ought  to  be  done  when  there  is  the  slightest  danger  of  her 
being  exposed  to  the  poison  of  variola. 

In  a  few  cases  of  successful  vaccination  of  the  mother,  especially  if  far 
advanced  in  pregnancy,  what  has  been  called  intra-uterine  vaccination  of  the 
foetus  occurs ;  the  child  proving  insusceptible  to  vaccination  after  birth. 

i  Gaz.  Hebdom.  de  Science  M6dicale  de  Bordeaux,  1887. 

*  Gazette  Hebdom.  de  Med.,  October.  1892. 

*  Cent.  f.  Gynakol.,  1892.  *  Ziemssen's  Encyclopaedia. 


CHRONIC  AND  ACUTE  DISEASES  IN  PREGNANCY.  431 

Scarlatina.  This  disease,  several  times  observed  in  the  puerperal, 
has  been  rarely  seen  in  the  pregnant  woman.  Of  141  cases  collected 
by  Olshausen,  in  only  7  did  the  disease  show  itself  before  labor.  In  3 
out  of  16  cases1  observed  by  Boxall,  the  disease  appeared  in  pregnant 
women.  Nevertheless,  it  is  probable,  as  suggested  by  Hervieux,2  after 
mentioning  a  case  under  his  own  care  in  which  scarlatina  occurred  in  a 
woman  six  months  pregnant,  and  caused  abortion,  and  a  similar  one 
observed  by  Dance,  that  a  great  number  of  other  cases  of  the  disease 
occurring  in  pregnancy  have  escaped  being  properly  recorded,  but,  from 
the  fact  that  the  disease  caused  abortion  or  premature  delivery,  have 
been  regarded  as  belonging  to  the  puerperal  rather  than  to  the  pregnant 
state. 

The  pregnant,  as  well^as  the  puerperal  condition,  adds  to  the  danger 
of  the  disease.  In  an  epidemic  of  scarlatina  which  occurred  in  Vienna 
in  1801,  abortion  occurred  in  all  pregnant  women  who  were  attacked, 
and  the  majority  died.  Bourgeois. 

One  of  Boxall's3  conclusions  is  the  following :  It  seems  possible 
that  the  poison  of  scarlet  fever,  like  that  of  smallpox,  may  occasionally, 
at  any  rate,  determine  premature  labor,  and  even  before  the  symptoms 
of  the  disease  have  had  time  to  develop. 

Another  of  his  conclusions  is,  that  if  labor  occurs  during  an  attack 
of  scarlatina,  pains  are  apt  to  be  feeble  throughout,  inertia  sets  in  early, 
and  there  is  a  liability  to  post-partum  hemorrhage. 

Thomas4  states  that  the  mortality  of  scarlatina  in  adults  is  greatest 
in  pregnant,  in  puerperal  women,  and  in  invalids. 

Rubeola.  The  number  of  reported  cases  of  measles  in  pregnancy  is 
small.  Gautier  has  collected  a  few,5  among  which  is  one  from  Fabricius 
of  Hildanus,  having  considerable  interest.  The  patient  of  Fabricius 
was  attacked  by  measles  in  the  middle  of  the  ninth  month  of  preg- 
nancy, and  the  fourth  day  of  the  disease  gave  birth  to  her  child,  which 
was  covered  with  the  eruption  of  measles.  In  a  case  under  my  own 
care,  the  patient  being  also  in  the  ninth  month  of  pregnancy,  premature 
labor  occurred  the  third  day  after  the  eruption  appeared ;  the  child  was 
born  apparently  well,  but  in  a  few  days  had  measles,  and  the  disease 
proved  fatal ;  the  mother  recovered.  Gautier's  conclusions  are  that  the 
disease  predisposes  to  miscarriage  from  the  death  of  the  fcetus,  and  that 
it  is  not  without  some  peril  to  the  mother.  Underbill's6  conclusions 
are  not  materially  different. 

Erysipelas.  This  may  be  a  very  serious  disease  for  the  mother  occur- 
ring near  the  end  of  preguancyv 

Lebedeff  found  in  the  skin  of  a  foetus  of  a  mother  suffering  with 
erysipelas  cocci  corresponding  with  Fehleisen's.  Hence  the  passing  of 
the  specific  organisms  of  the  disease  from  the  mother  to  the  foetus  is 
probable,  but  authorities  do  not  regard  it  as  proved. 

Influenza.  Influenza  interrupts  gestation  in  many  cases.  Felkin 
saw7  abortion  or  premature  labor  occur  in  six  out  of  seven  women 

1  London  Obstetrical  Society's  Transactions,  vol.  xxx.,  1889. 

2  Maladies  Puerp6rales.  3  Op.  cit. 
*  Zeimssen's  Cyclopaedia.                                           5  Annales  de  Gynficologie,  1879. 
8  Obstetrical  Society  of  Great  Britain  and  Ireland. 

7  Transactions  of  the  Edinburgh  Obstetrical  Society,  vol.  xvii. 


432  THE  PA THOLOG  Y  OF  PREGNANCY. 

attacked  with  the  disease.  Fruitnight  has1  given  given  similar  testi- 
mony. On  the  other  hand,  Ballantyne  states2  that  he  has  seen  few 
miscarriages  which  he  could  attribute  to  influenza.  He,  however,  adds : 
"Gottschalk  and  Miiller  both  saw  two  cases,  Mijinleff  saw  one,  and 
Trossat  several  in  which  the  gestation  was  interrupted  by  influenza ; 
and  Ammen  observed  six  in  which  the  foetus  died  in  utero,  and  was 
expelled  some  weeks  later."  Vinay  says  that  during  the  epidemics  of 
1891  and  1892  he  saw  influenza  in  twenty-two  pregnant  women;  in  six 
there  was  premature  labor,  and  in  one  he  induced  labor  at  the  eighth 
month  because  of  grave  pulmonary  accidents.  He  advises,  in  case 
uterine  pains  occur,  absolute  rest  in  bed  and  a  rectal  injection  of  twenty- 
five  to  thirty  drops  of  laudanum,  repeated  if  necessary.  He  adds,  "The 
employment  of  antipyrin,  so  useful  in  the  uterine  colics  following  deliv- 
ery, here  meets  a  double  indication.  That  cannot  be  said  of  quinine, 
the  administration  of  which  should  be  restricted,  for  its  action  upon  the 
gravid  uterus,  especially  if  the  contractility  of  this  organ  is  already 
modified  and  rendered  more  excitable  by  the  disease,  cannot  be  disputed." 

Diphtheria.  This  disease  has  been  rarely  observed  in  pregnant  women, 
and,  according  to  Miiller,  in  the  majority  of  cases  it  shows  no  injurious 
influence  upon  the  life  of  the  foetus,  nor  upon  the  course  of  the  preg- 
nancy. Tracheotomy  has  been  performed,  and  the  gestation  gone  to 
term  ;  in  another  instance  Csesarean  section  was  done  after  death  of  the 
mother,  and  a  living  child  removed.  Pregnancy  does  not  coutra-indi- 
cate  tracheotomy. 

Pertussis.  A  curious  observation  is  credited  to  Beatty  by  Miiller ; 
A  woman  advanced  in  pregnancy  suffered  with  whooping-cough,  but 
labor  occurred  at  the  normal  time,  and  after  it  all  the  symptoms  rapidly 
disappeared. 

1  New  York  Journal  of  Gynecology  and  Obstetrics,  vol.  iii. 

2  Transactions  of  the  Edinburgh  Obstetrical  Society,  vol.  xix. 


CHAPTEK  Y. 

DISEASES    OF    THE    SEXUAL    ORGANS — URINARY   DISORDERS — 
TRAUMATISMS. 

VEGETATIONS  OF  THE  VULVA.  Papillary  hypertrophy  may  occur 
at  various  parts  of  the  vulval  surface,  giving  rise  to  wart-like  elevations, 
in  the  pregnant  woman.  While  probably  in  the  majority  of  cases  these 
growths  have  a  specific  origin,  yet  in  some  it  is  believed  that  they  result 
from  the  irritation  of  parts  rendered  more  vascular  by  pregnancy,  like 
plants  springing  up  luxuriantly  from  a  moist  soil.  The  proof  of  their 
non-specific  character  is  given  by  the  fact  that  they  may  spontaneously 
disappear  when  the  pregnancy  is  over.  They  may  occupy  the  nymphse, 
the  vestibule,  the  hood  of  the  clitoris,  the  labia  majora,  the  adjacent 
skin,  the  vaginal  orifice,  and  in  some  cases  extend  into  the  vagina. 

Vinay  advises  pencilling  the  growths,  if  mild  means  fail,  once  or 
twice  a  day  with  a  mixture  of  one  part  of  salicylic  acid  to  fifteen  of 
acetic  acid. 

Unless  large,  and  so  extensive  that  they  obstruct  the  birth-canal, 
active  treatment  in  pregnancy  is  not  advisable,  for  excision  might  be 
attended  with  considerable  hemorrhage,  and  followed  by  abortion  or  pre- 
mature labor,  or  inflammation  of  lymphatics  or  veins.  When  removed 
they  are  very  liable  to  return,  and  their  probable  spontaneous  disap- 
pearance after  pregnancy  is  an  additional  reason  for,  refraining  active 
treatment.  The  surfaces  affected  must  be  kept  apart  as  much  as  possible, 
and  disinfectant  or  astringent  solutions  applied ;  one  of  the  best  local 
applications  is  a  solution  of  carbolic  acid.  Charpentier  states  that  in 
two  pregnant  women  these  growths  disappeared  by  isolating  the  affected 
parts,  and  applying  compresses  dipped  in  Labarraque's  solution. 

Kapid  growth  and  great  volume  of  the  vegetations,  the  pain  they  cause,  the 
constant  purulent  discharge,  the  interference  with  walking,  working,  and  sleeping, 
and  finally  the  danger  of  hemorrhage  are,  Vinay  says,  indications  for  excision. 
He  adds  that  these  growths,  in  modifying  the  texture  of  the  skin  upon  which  they 
are  implanted,  predispose  to  rupture  of  the  perineum  and  of  the  labia  majora. 

The  preferable  means  of  removal  is  the  curette,  Volkmann's,  the  patient  hav- 
ing been  anaesthetized ;  the  operatibn  requires  from  fifteen  to  twenty  minutes ; 
hemorrhage  continuing  after  it  is  arrested  by  compression  with  antiseptic  gauze, 
or  by  the  application  of  the  thermo-cautery. 

PROLAPSE  OF  THE  VAGINA.  This  is  to  be  treated  by  astringent 
injections,  by  having  the  bladder  frequently  emptied,  especially  if  a 
cystocele  is  associated  with  the  prolapse,  and  by  wearing  a  suitable 
pessary ;  the  elastic  ring  will  in  most  cases  be  best ;  if  a  pessary  cannot 
be  worn,  a  large  tampon  of  absorbent  cotton  dipped  in  a  mixture  of 
tannin  and  glycerin  may  be  used ;  this  tampon  should  be  removed  each 
night  and  a  fresh  one  introduced  in  the  morning. 

28 


434  THE  PATHOLOGY  OF  PREGNANCY. 

LEUCORRHCKA.  It  is  not  uncommon  for  a  pregnant  woman  to  have 
a  more  or  less  abundant  milk-like  discharge  from  the  vagina ;  it  arises 
from  a  simple  or  catarrhal  vaginitis,  induced  in  part  by  the  increased 
congestion  of  pregnancy.  Another  form  of  vaginitis  may  also  occur ; 
it  was  first  described  by  Deville  in  1844,  and  called  by  him  granular 
vaginitis ;  he  believed  it  peculiar  to  pregnancy,  but  it  may  occur  in  the 
non-pregnant,  though  more  frequent  in  the  former  condition.  It  is 
characterized  by  the  formation  of  a  large  number  of  hemispherical  ele- 
vations about  the  size  of  a  hemp-seed  upon  the  vaginal  surface,  making 
it  rough,  by  burning  and  itching,  and  by  a  rather  profuse  yellowish 
discharge  which  irritates  the  parts  with  which  it  comes  in  contact  in 
passing  out  of  the  vagina.  Other  vaginal  discharges  may  be  caused  by 
gonorrhoeal  infection  or  by  cervical  endometritis. 

Winckel  described,  in  1871,  a  condition  which  he  observed  in  three  pregnant 
women,  and  which  was  characterized  by  the  presence  upon  the  vagina  of  a  vast 
number  of  transparent  cysts,  fifteen  or  twenty  being  found  upon  a  spot  the  size 
of  a  dollar,  and  usually  associated  with  hypersecretion ;  most  of  the  cysts  con- 
tained gas,  and  when  punctured  collapsed  with  a  sound  readily  heard.  He 
named  the  disease  colpohyperplasia  cystica.1 

The  treatment  of  the  vaginal  discharges  of  pregnancy  will  be,  in  the 
slighter  cases,  by  tepid  injections  of  solutions  of  astringents,  as  of 
alum,  borax,  salts  of  zinc,  etc.,  or  a  mixture  of  creolin,  usually  one- 
fourth  a  teaspoonful  to  a  pint  of  water ;  in  severer  cases,  in  addition 
to  cleansing  injections  of  a  two  per  cent,  solution  of  carbolic  acid,  of 
potassic  chlorate,  or  of  common  salt,  a  cotton  tampon  inclosing  half  a 
teaspoonful  of  powdered  alum  and  of  subnitrate  of  bismuth  may  be 
passed  to  the  upper  part  of  the  vagina  and  left  there  for  twelve  or 
twenty-four  hours,  when,  by  means  of  a  string  which  has  been  tied  to 
it  before  its  introduction,  it  is  removed ;  the  tampon  may  be  repeated 
the  following  day.  Instead  of  the  dry  tampon  just  advised,  one  of 
cotton  dipped  in  a  mixture  of  boric  acid  and  glycerin,  1  to  10,  may  be 
used,  or  of  tannin  and  glycerin.  If  the  vaginitis  be  gonorrhoeal,  it 
will  be  advisable,  beside  the  means  that  have  been  mentioned,  to  apply 
with  a  brush  a  solution  of  nitrate  of  silver  to  the  exposed  vaginal  wall, 
or  to  use  injections  of  a  solution  of2  corrosive  sublimate ;  during  labor 
the  vagina  must  be  well  cleansed,  a  disinfectant  solution  being  used,  so 
if  possible  to  prevent  the  contact  of  any  infectious  matter  with  the 
child's  face,  lest  some  of  it  might  find  its  way  to  either  conjunctiva  and 
a  specific  conjunctivitis  result. 

POSITIONAL  DISOEDERS  OF  THE  UTERUS.  Prolapse  and  Prod- 
dentia.  In  prolapse  of  the  uterus  the  organ  is  still  within  the  vulval 
orifice,  but  if  it  protrudes  from  that  orifice  there  is  procidentia.  The 
uterus  in  the  fourth  month  of  pregnancy  begins  to  ascend,  and  most 
cases  of  prolapse  are  thus  spontaneously  cured.  But  in  the  pregnant 
as  in  the  non-pregnant  condition  the  same  causes,  such  as  sudden  pres- 
sure upon  the  abdomen,  or  a  fall,  or  jumping  from  an  elevated  position, 
may,  especially  if  the  bladder  be  full,  cause  acute  uterine  prolapse. 

1  See  Winckel's  work  on  Diseases  of  Women  for  full  description. 
*  Runge  advises  applying  a  solution  of  chloride  of  zinc. 


DISEASES  OF  THE  SEXUAL  ORGANS.  435 

Most  cases,  however,  of  prolapse  of  the  uterus  in  pregnancy  are  those 
in  which  the  prolapse  was  present  before  the  pregnancy,  for  even  proci- 
dentia  of  the  uterus  does  not  prevent  impregnation,  as  the  organ  may 
be  spontaneously  replaced  when  the  subject  lies  down ;  and  further, 
instances  in  which  coition  taking  place  through  the  dilated  os,  fecun- 
dation has  followed.  Hypertrophy  of  the  vaginal  portion  has  some- 
times been  mistaken  for  prolapse  of  the  uterus,  but  the  fundus  occupies 
its  normal  place.  Amputation  of  the  cervix  occasionally  is  necessary  in 
this  hypertrophy. 

Kleinschmidt1  has  narrated  a  case  of  prolapse  of  the  uterus  in  pregnancy,  the 
organ  protruding  about  an  inch  from  the  vulva  if  the  patient  was  erect,  when 
the  pregnancy  was  only  six  weeks  advanced  ;  at  six  months  and  a  half  the  pro- 
trusion still  remained,  even  when  the  patient  was  recumbent,  and  a  bandage  was 
worn  to  support  the  organ.  Kleinwachter  states  that  in  case  of  considerable 
prolapse  and  injudicious  treatment,  especially  if  reposition  be  neglected,  the 
organ  may  become  incarcerated,  and  the  pregnancy  thereby  be  arrested.  He  denies 
that  it  is  possible  in  case  of  complete  prolapse  or  procidentia  for  the  pregnancy 
to  be  completed,  because  of  the  injuries  to  which  the  organ  is  exposed.  Winckel 
believes  that  a  complete  prolapse  of  the  gravid  uterus  may  occur  in  the  first 
half  of  pregnancy,  but  rejects  the  reported  cases  of  this  accident  during  labor. 

The  treatment  of  prolapse  of  the  uterus  is  reduction,  the  recumbent 
position  for  the  patient,  and  the  wearing  of  a  suitable  pessary.  In  cases 
of  difficult  reduction  the  patient  may  be  anaesthetized,  or  a  solution  of 
cocaine  applied  previous  to  the  manipulation.  Should  the  pessary  not 
retain  the  reduced  uterus,  a  large  vaginal  tampon  of  absorbent  cotton 
or  of  prepared  lamb's- wool,  well  covered  with  an  ointment  of  creolin, 
may  be  employed,  or  antiseptic  gauze,  and  a  bandage  used  to  keep  it  in 
place.  Of  course,  the  tampon  is  removed  at  night  and  a  fresh  one 
introduced  in  the  morning  before  the  patient  rises.  Abortion  is  indi- 
cated if  a  prolapsed  uterus  becomes  incarcerated. 

Anteflexion  and  Anteversion  of  the  Uterus.  Anteflexion  of  the  preg- 
nant uterus  is  an  exaggeration  of  the  original  condition,  and  therefore 
is  by  most  regarded  as  normal,  though  very  great  importance  is  attached 
to  it  as  a  cause  by  Graily  Hewitt  of  vomiting ;  it  very  seldom  reaches 
such  a  degree  as  to  be  pathological.  The  rule  is  that  if  the  uterus  be 
greatly  anteflexed  sterility  results,  caused  not  so  much  by  the  displace- 
ment, but  by  conditions  associated  with  it.  An  anteflexion,  or  an  ante- 
version,  in  the  earlier  months  may  cause  great  irritability  of  the  bladder 
and  other  inconveniences ;  but  unless  some  pathological  condition  be 
associated  with  the  positional  disorder,  it  is  not  probable  there  will  be 
any  arrest  of  pregnancy ;  nor  $oes  it  seem  possible  that  the  uterus  can 
become  incarcerated,  and  its  fundus  fixed  behind  the  pubic  joint.  Ante- 
version  of  the  uterus  is  physiological  in  multigravida?  in  the  latter  part 
of  pregnancy,  for  the  relaxation  of  the  abdominal  wall  permits  the 
uterus  to  fall  forward  ;  if  this  relaxation  be  very  great,  it  may  rest  upon 
the  thighs  when  the  patient  is  sitting.  The  condition  is  sometimes 
spoken  of  as  hanging  belly,  or  pendulous  abdomen.  The  occurrence 
of  this  accident  may  occur  in  diastasis  of  the  recti  muscles.  Very 
great  discomfort  commonly  results  from  this  condition  in  pregnancy,  and 
the  entrance  of  the  head  of  the  foetus  into  the  pelvic  cavity  be  hindered. 

1  American  Journal  of  Obstetrics,  vol.  xviii. 


436 


THE  PATHOLOGY  OF  PREGNANCY. 


In  labor  the  uterine  contractions  work  at  much  disadvantage  from  the 
malposition  of  the  womb.  The  remedy  is  found  in  a  firm,  properly 
applied  bandage. 

Retroversion  and  Reiroflexion.  Posterior  displacements  of  the  uterus 
in  pregnancy  are  graver  conditions.  A  woman  with  a  retroverted  uterus 
rarely  becomes  pregnant ;  hence,  if  the  uterus  be  found  retroverted  in 
pregnancy,  it  is  probably  an  accident  that  has  occurred  after  gestation 
has  begun.  On  the  other  hand,  a  woman  who  has  a  retroflexed  uterus 
may  become  pregnant  more  frequently  than  one  whose  uterus  is  in  the 


FIG.  171. 


RETROFLEXION  OF  THE  GRAVID  UTEKUS  WITH  INCARCERATION. 
A.  Bladder.    B.  Internal  orifice.    C.  External  orifice.    D.  Urethra.    E.  Vagina.    F.  Rectum. 

normal  position,  for  the  deviation  is  very  often  the  cause  of  abortion. 
In  regard  to  the  occurrence  of  retroversiou  of  the  pregnant  uterus,  there 
has  been  much  controversy  as  to  whether  the  deviation  is  sudden  or 
gradual,  and  as  to  whether  distention  of  the  bladder  is  cause  or  conse- 
quence.    It  may  be  admitted  that  each  form  of  displacement  can  take 
Slace — that  is,  in  some  cases  it  is  gradual,  in  others  sudden,  and  that 
istention  of  the  bladder  may  occasionally  be  a  cause,  while  in  all  cases 
it  is  one  of  the  gravest  consequences  of  the  change  of  position. 

In  the  majority  of  cases  of  posterior  displacement  of  the  gravid  uterus 
spontaneous  cure  occurs,  the  uterus  gradually  rising  out  of  the  pelvis. 
Further,  in  some  cases  of  retroflexed  uterus,  as  first  suggested  by 
Merriman,  and  as  confirmed  by  the  observations  of  Oldham1  and  Stille,2 
pregnancy  may  go  on  to  term,  or  near  it,  though  the  uterus  remains 
retroflexed. 


1  London  Obstetrical  Society's  Transactions,  vol.  xi. 


2  Memorabil.,  1881. 


DISEASES  OF  THE  SEXUAL  ORGANS. 

FIG.  172. 


437 


DIAGRAM  OF  PARTIAL  RETROFLEXION.    (OLDHAM.) 

Oldham's  case  was  one  in  which  at  term  he  found  the  head  of  the  child  occu- 
pying the  fundus  of  the  uterus,  which  was  in  the  pelvic  cavity,  while  the  lower 
segment  of  the  uterus  was  raised  considerably  above  the  pelvic  brim.  He  suc- 
ceeded in  delivering  the  woman  of  a  dead  child,  by  first  introducing  the  finger 
into  the  child's  anus,  failing  to  reach  the  bend  of  the  child's  thigh,  thus  exerting 
traction,  and  he  was  enabled  after  considerable  effort  to  draw  the  breech  a  little 
lower,  and  some  elevation  of  the  head  followed;  then  pressure  upon  the  lower 
part  of  the  tumor,  while  external  pressure  was  made,  caused  the  fundus  to  ascend 
above  the  brim  and  into  the  abdominal  cavity ;  the  os  uteri  now  being  accessible, 
a  foot  was  brought  down,  and  the  child  delivered.  In  Stille's  case  a  retroflexion 
at  the  fourth  month  of  pregnancy  caused  retention  of  urine,  but  no  interference 
with  evacuations  from  the  bowels.  Replacement  being  impossible,  daily  cathe- 
terization  of  the  bladder  was  done ;  development  of  the  uterus  continued,  the 
child's  head  remaining  in  the  pelvic  cavity,  the  body  above.  Labor  came  on 
seven  weeks  prematurely,  and  delivery  was  accomplished  by  podalic  version. 

Further,  nature  may  end  the  case  by  abortion ;  this  result  is  not 
unfrequent ;  but,  none  of  the  events  which  have  been  mentioned  occur- 
ring, symptoms  of  incarceration  supervene.  The  uterus  confined  to  the 
sacral  cavity,  possibly  by  the  adhesions  of  an  old  peritonitis  in  some 
cases,  continues  its  development ;  there  result  retention  of  urine  and 
obstruction  of  the  rectum  ;  uraemia  and  local  or  general  peritonitis  may 
occur ;  the  bladder  may  rupture,  or  there  may  be  either  a  simple  or 
diphtheritic  cystitis  from  retention  of  urine,  and,  as  a  consequence, 
detachment  of  the  whole  or  of  parts  of  the  vesical  mucous  membrane. 

Valenta1  has  reported  a  case  in  which  retroflexion  in  the  fifth  month 
caused  gangrene  of  the  bladder,  perforation  into  the  small  intestine,  and 
death  of  the  patient. 

The  diagnosis  of  retroflexion  or  of  retroversion  of  the  pregnant  uterus 
will  not  usually  present  any  great  difficulty.  First,  the  fact  of  preg- 

1  See  Kormann. 


438 


THE  PATHOLOGY  OF  PREGNANCY. 


nancy  is  to  be  established  ;  next,  the  bladder  is  to  be  emptied,1  a  flexible 
or  a  male  catheter  being  used  for  this  purpose,  and  in  case  this  is  im- 
possible aspiration  would  be  preferable  to  leaving  the  organ  distended ; 
then  digital  examination  by  the  vagina  and  by  the  rectum ;  and,  finally, 
bimanual  examination  ought  to  remove  all  doubts  as  to  the  nature 
of  the  disorder. 

FIG.  173 


SHOWING  UTERUS  AND  BLADDER  FROM  A  FATAL  CASE  (DR.  CHAMBERS').    SPECIMEN  IN 
ST.  THOMAS  (ROBERT  BABNES). 

Having  discovered  the  displacement,  the  treatment  will  be,  in  the 
simple  cases  in  which  the  uterus  is  mobile,  digital  or  bimanual  replace- 
ment of  the  organ,  and  the  introduction  of  a  pessary.  The  patient  must 
avoid  compression  of  the  abdomen,  constipation,  straining  at  stool, 
and  allowing  accumulation  of  urine  in  the  bladder.  She  ought  each 
day  occupy  the  knee-chest  position,  or  u  the  Mahomedan  attitude  of 
prayer,"  for  a  short  time,  and  when  recumbent  must  take  an  abdomino- 
lateral  position.  At  four  months  the  pessary  may  be  removed.  In 
other  cases,  the  uterus  not  being  mobile,  and  if  no  evidences  of  inflam- 
mation are  present,  efforts  at  gradual  reposition  may  be  made  as  follows  : 

1  The  practitioner  must  remember  that  in  some  cases  there  is  ischuria  paradoxa,  and  not  let 
himself  be  deceived. 


DISEASES  OF  THE  SEXUAL  ORGANS. 


439 


Let  the  patient  take  the  knee-chest  position  ;  then  the  practitioner  may, 
by  two  fingers  introduced  into  the  vagina,  press  upon  the  posterior  wall 
of  the  uterus,  or  the  fingers  may  exert  this  pressure  through  the  rectum  ; 
no  violence  should  be  used;  generally  immediate  reposition  is  not  ex- 
pected, but  a  slight  gain  being  made  from  day  to  day,  final  success  may 
be  obtained  after  a  week,  or  even  longer  time.  Another  method,  either 
employed  alone  or  assisting  that  which  has  been  given,  is  to  introduce 


FIG.  174 


RETEOVERSION  OF  PREGNANT  UTERUS  WITH  INCARCERATION. 

into  the  vagina  the  broad  blade  of  Sims's  speculum,  the  broader  the 
better,  and  with  it  not  only  draw  back  the  perineum,  but  also  press  up 
in  the  posterior  vaginal  cul-de-sac,  thus  pushing  the  body  of  the  uterus 
up,  and  at  the  same  time  drawing  the  neck  backward ;  the  last  may  be 
assisted  by  seizing  the  cervix  with  a  tenaculum  and  drawing  it  toward 
the  posterior  vaginal  wall.  This  entire  method  may  be  summarized  in 
push  and  pull.  Let  the  operator,  however,  always  have  as  his  motto, 
non  m  sed  arte.  In  manual  replacement  care  Is  to  be  taken  to  direct  the 
fundus  of  the  uterus  toward  one  of  the  sacro-iliac  joints,  thus  avoiding 
the  sacral  promontory. 

Another  method  which  counts  some  success  is  the  use  of  continuous  elastic 
pressure  by  means  of  a  rubber  bag  distended  with  air  or  water,  introduced  into 
the  vagina  or  into  the  rectum.  But  neither  organ  is  very  tolerant  of  such  an 
instrument ;  this  is  especially  true  as  to  the  rectum  ;  moreover,  it  does  more  harm 
than  good  when  the  pressure  is  made  through  the  vagina  if  the  fundus  of  the 
uterus  be  lower  than  the  cervix,  for  then  the  pressure  will  be  greater  upon  the 
latter  than  upon  the  former.  I  doubt,  indeed,  whether  it  is  of  any  value,  even 


440 


THE  PATHOLOGY  OF  PREGNANCY. 


if  the  uterus  is  simply  transverse  ;  the  space  furnished  by  the  rectum  below  the 
retroverted  uterus  is  so  small  that  but  slight  force  can  be  exerted  through  it.  If 
an  anaesthetic  is  used  when  efforts  at  reposition  are  made,  of  course  the  patient 
cannot  be  in  the  knee-chest  position,  but  must  lie  upon  her  back  or  upon  her 
side.  If  reduction  be  impossible  and  symptoms  of  incarceration  occur,  the  only 
remedy  is  causing  abortion. 

In  a  case  of  Olshausen's,  in  which  reposition  failed  because  of  narrowed  osteo- 
malacic  pelvis,  and  puncture  through  the  vagina  did  not  cause  abortion,  ex- 
tirpation of  the  uterus  was  successfully  employed. 


5    6 


FIG.  175. 


4 


SACCIFORM  DILATATION  OF  THE  POSTERIOR  WALL  OF  THE  UTERUS. 

1.  Os  uteri.  2.  Artificial  os.  The  distance  between  the  two  was  about  three  inches  and  a  half, 
9  centimetres.  The  distance  from  the  fund  us  of  the  uterus  (6)  to  the  os  was  6.7  inches,  or  17  centi- 
metres, while  that  extending  from  the  same  point  (5)  to  the  new  opening  was  9  inches,  or  23  centi- 
metres. The  distance  from  the  os  to  the  median  point  of  the  fundus  was,  following  the  curve  of 
the  anterior  wall,  8.2  inches,  21  centimetres,  but  following  the  curve  of  the  posterior  wall,  18.1 
inches,  46  centimetres. 

r  Sacciform  Dilatation  of  the  Posterior  Wall  of  the  Uterus.  A  condition  rarely 
observed,  and  which  has  been  mistaken  in  some  cases  for  retroversion  of  the 
pregnant  uterus,  was  very  fully  described  by  Depaul1  in  1876.  It  has  been  called 
sac-like  dilatation  of  the  posterior  wall  of  the  uterus.  Fig.  175  represents 
the  post-mortem  appearance  of  the  uterus  of  a  patient  under  the  care  of  Depaul. 

1  Archives  de  Tocologie. 


DISEASES  OF  THE  SEXUAL  ORGANS.  441 

It  was  impossible  for  him  to  find  the  os  uteri,  the  patient  being  in  labor,  and  he 
made  an  opening  through  what  the  autopsy  proved  to  be  the  posterior  wall  of. 
the  uterus.     The  patient  died  undelivered. 

Hernia  of  the  Uterus.  Ventral  Hernia.  In  rare  instances  the  preg- 
nant uterus  has  in  part  protruded  at  the  abdominal  ring,  the  disease  being 
known  as  uterine  exomphalos,  or  uterine  umbilical  hernia.  In  Murray's 
case1  more  than  two-thirds  of  the  uterus  thus  protruded  in  the  latter  part 
of  pregnancy  ;  reduction  was  readily  accomplished,  and  a  bandage  pre- 
vented reproduction  of  the  hernia.  In  Oliver's  case,2  not  seen  until 
Jabor  began,  a  cone-like  mass — the  base  of  the  cone  being  at  the  um- 
bilicus— was  observed  projecting  from  the  abdomen.  After  the  delivery 
of  the  child  the  tumor  was  still  evident,  and  proved  to  be  the  upper 
portion  of  the  uterus  containing  an  enormously  developed  placenta,  the 
weight  being  eight  pounds,  as  estimated  after  its  expulsion.3  Reduction 
of  the  hernia  was  readily  effected.  The  woman  had  umbilical  hernia  in 
childhood. 

Examples  of  hernia?  in  pregnancy  resulting  from  dilatation  of  an 
abdominal  cicatrix  have  been  given  by  Boivin  and  others.  More 
frequently,  however,  hernia?  at  the  linea  alba  have  been  observed  ; 
separation  of  the  recti  muscles  occurring,  the  uterus  projects  in  the  in- 
terval. 

Prochownick,  in  a  recent  paper  upon  diastasis  of  the  abdominal  muscles  in 
childbed,4  states  that  English  women  are  less  liable  than  German  women  to  pen- 
dulous abdomen  after  confinement,  because  they  remain  longer  in  bed,  and  espe- 
cially because  they  wear  well-fitting  bandages  after  getting  up.  His  view  as  to 
the  disorders  that  arise  in  the  lying-in  from  diastasis  of  the  recti  muscles  will  be 
referred  to  elsewhere. 

The  treatment  of  ventral  hernia  is  the  same  as  that  of  pendulous 
abdomen. 

Orural  and  Inguinal  Hernia.  Winckel5  remarks  that  in  view  of 
the  possibility  of  the  uterus  entering  into  the  various  canals  passing 
from  the  false  and  from  the  true  pelvis,  such  terms  as  inguinal  hernia 
of  the  uterus,  crural,  obturator,  ischiatic,  etc.,  have  been  used,  but  as  a 
matter  of  fact  the  uterus  has  been  found  only  in  the  hernial  sac  of  in- 
guinal and  crural  hernise. 

Eisenhart6  states  that  hernia  of  the  gravid  uterus  is  nearly  as  rare  as  hernia  of 
the  non-gravid  organ  ;  the  slight  preponderance  in  number  of  the  former  is  prob- 
ably due  to  the  fact  that  pregnancy  directs  attention  to  a  condition  which  would 
otherwise  be  unnoticed.  In  his  historical  references,  he  says  that  Nicolaus  Pol, 
1531,  reported  the  first  case ;  Csesarean  section  was  done,  the  mother  survived 
three  days,  the  child  lived  to  be  one  year  and  a  half  old.  In  April,  1610,  Sennert 
operated  on  a  case,  the  mother  lived  twenty-five  days,  and  the  child  until  nine 
years  and  a  half  old.  Saxtorph's  and  Ledesma's  cases  are  next  given ;  the  latter 
occurred  in  1840.  Rektorzik  reported  a  case  in  1860  ;  the  Caesarean  operation 
was  done,  the  mother  died,  but  the  child  lived.  Inguinal  hernia  is  frequently 

1  London  Obstetrical  Society's  Transactions,  vol.  1. 

«  Western  Journal  of  Medicine,  1867. 

3  In  a  private  communication  Dr.  Oliver  states  that  he  did  not  weigh  the  placenta,  but  he  did 
the  child,  its  weight  being  but  four  and  a  half  pounds,  and  the  placenta  seemed  to  be  nearly  twice 
as  heavy.  The  heaviest  placenta  mentioned  in  obstetric  works,  I  believe,  is  that  described  by 
Stein,  and  referred  to  by  Velpeau — its  weight  being  six  pounds. 

*  Archiv  fur  Gynakologie,  1886. 

&  Op.  cit.  «  Archiv  fiir  Gynakologie,  1885. 


442  THE  PATHOLOGY  OF  PREGNANCY. 

associated  with  uterus  bicornis  or  didelphys.  In  Winckel's  case,  reported  by 
Eisenhart,  the  hernia  occurred  suddenly  in  the  fourth  month  of  pregnancy  ;  the 
right  horn  of  the  uterus  was  concerned.  Scanzoni  has  reported  a  case  of  inguinal 
hernia  in  which  two  pregnancies  occurred  in  one  year ;  one  of  the  pregnancies 
ended  by  spontaneous,  the  other  by  artificial,  abortion. 

Adams1  has  collected  23  cases  of  hernia  of  the  gravid  uterus  ;  9  of  these  were 
of  inguinal  hernia ;  in  one  spontaneous  delivery  occurred,  in  a  second  abortion 
was  produced,  in  a  third  Porro's  operation  (Winckel's  case),  and  in  the  rest  the 
Csesarean  operation ;  four  mothers  died,  two  children  lost,  including  the  abortion. 
One  crural,  mother  died,  child  saved.  Four  umbilical,  no  life  lost.  Eight  ven- 
tral, all  mothers  recovered ;  craniotomy  in  one  case,  and  in  another  the  child 
was  stillborn. 

In  these  hernias  Winckel  advises  abortion.  If  the  foetus  be  viable, 
the  Caesarean  section  should  be  done  at  the  end  of  gestation,  and  then, 
if  the  uterus  can  be  restored  to  the  abdominal  cavity,  this  is  done,  but 
if  impossible  the  organ  must  be  removed. 

STRUCTURAL  DISEASES  OF  THE  UTERUS.  Two  only  of  these  require 
consideration,  fibroid  tumors  and  malignant  growths. 

Fibroids  of  the  Uterus.  A  relative  sterility  results  from  fibroid 
tumors  of  the  uterus  ;  thus  while  the  average  sterility  of  women  is  one 
in  eight,  that  of  those  having  these  growths  is  one  in  three.  In  the 
great  majority  of  women  having  uterine  fibroids  pregnancy  is  not  in- 
terrupted ;  if  the  tumors  be  situated  at  the  fundus,  it  is  thought  abor- 
tion in  the  earlier  mouths  is  very  liable  to  occur  ;  placenta  pravia  is 
very  much  more  frequent  in  cases  of  fibroids.  The  tumors  usually  in- 
crease in  size,  and  become  softer  during  pregnancy,  and  after  pregnancy 
may  greatly  lessen2  in  bulk  ;  but  such  changes  are  observed  more  espe- 
cially in  those  that  have  a  predominance  of  muscular  tissue. 

The  treatment  of  fibroid  tumors  in  pregnancy  is  chiefly  symptomatic. 
Thus,  if  the  tumor  becomes  incarcerated  in  the  pelvic  cavity,  an  effort  is 
made  to  push  it  up  in  the  false  pelvis ;  if  hemorrhage  occurs,  rest,  cold 
drinks,  opium,  or  finally  the  vaginal  tampon  may  be  employed.  Mis- 
carriage is  almost  inevitable. 

Many  cases  of  small  fibroids  do  not  interfere  with  the  progress  of 
the  pregnancy,  and,  indeed,  may  not  be  discovered  until  after  labor  is 
over. 

Submucous  cervical  myomata,  it  is  generally  advised,  should  be  enu- 
cleated during  pregnancy  in  order  to  make  the  birth-canal  free  and  to 
avoid  subsequent  necrosis. 

The  question  of  producing  abortion  could  only  be  considered  in  those 
cases  in  which  a  Ca3sarean  operation  will  be  necessary  at  term  and  the 
patient  refuses  it. 

In  general,  the  removal  of  these  tumors  in  pregnancy  will  be  done  in 
just  such  conditions  as  imperatively  require  this  operation  were  the 
patient  not  pregnant. 

Malignant  Diseases  of  the  Uterus.  If  cancer  or  sarcoma  occupy  the 
fuudus  of  the  uterus,  there  is  little  probability  of  pregnancy  occurring, 
and  a  certainty  of  abortion  should  it  occur.  Cancer  of  the  neck  does 

1  American  Journal  of  Obstetrics,  1889. 

2  Dr.  Darrach  tells  me  of  having  many  years  ago  attended  a  woman  in  labor,  and  after  the 
child  was  born  found  the  uterus  so  large  he  believed  there  was  a  second  child.    Waiting  two 
hours,  he  made  a  careful  examination,  and  found  the  enlargement  was  due  to  a  fibroid  tumor.    Ex- 
amining the  patient  some  months  after  he  could  find  no  trace  of  the  tumor. 


DISEASES  OF  THE  SEXUAL  ORGANS.  443 

not  present  such  hindrance  to  pregnancy,  and  the  latter,  provided  the 
malady  involves  only  the  vaginal  portion,  most  frequently  continues  to 
term.  The  disease  is  unfavorably  affected  by  gestation.  Should  the 
cancer  be  limited  to  the  vaginal  cervix,  and  show  any  progress,  ampu- 
tation ought  to  be  done  at  once.  The  operation  has  been  performed  in 
some  cases  without  interruption  of  the  pregnancy.  Even  when  the 
affection  is  more  extensive  and  gives  rise  to  copious  purulent  and  hem- 
orrhagic  discharges  an  operation  for  partial  removal  of  the  cervix,  taking 
away  all  the  diseased  tissue  possible,  is  proper. 

Kaltenbach  has  reported  the  case  of  a  woman  five  months  pregnant,  who  had 
upon  the  anterior  lip  a  carcinomatous  nodule  the  size  of  a  hazlenut;  it  was  re- 
moved by  a  wedge-shaped  excision,  and  the  pregnancy  went  to  term.  Four 
years  later  the  woman,  then  in  the  seventh  month  of  pregnancy,  had  a  similar 
tumor  the  size  of  a  walnut  in  the  posterior  lip ;  again  a  wedge-shaped  excision 
of  the  diseased  portion,  and  the  pregnancy  was  not  interrupted. 

If  the  disease  has  advanced  to  the  internal  os,  vaginal  extirpation  of  the 
uterus  is  indicated  in  cases  where  the  pregnancy  has  not  advanced  beyond  three 
months.  In  a  case  of  this  kind  Olshausen  first  produced  abortion,  and  then 
removed  the  uterus. 

The  induction  of  abortion  or  of  premature  labor  is  not  generally 
regarded  with  favor ;  nevertheless,  in  some  cases  the  alternatives  are, 
when  labor  comes  on  spontaneously,  the  Csesarean  operation  or  craui- 
otomy. 

OVARIAN  TUMORS.  If  an  ovarian  tumor  be  small,  it  usually  causes 
no  serious  interference  with  pregnancy ;  but  if  the  tumor  be  large,  the 
pregnancy  in  many  cases  ends  in  abortion,  or  in  premature  labor. 
Other  accidents  are  inflammatory  adhesions  between  the  tumor  and  the 
fundus  of  the  uterus,  rupture  of  the  cyst  wall,  twisting  of  the  pedicle 
of  the  tumor,  followed  probably  by  hemorrhages  into  the  cyst,  and 
more  or  less  extensive  adhesions  through  which  the  tumor  receives  its 
nourishment.  In  some  cases,  when  the  tumor  is  not  large,  it  may 
become  wedged  in  the  pelvic  cavity. 

The  treatment  of  ovarian  tumors,  so  long  as  they  do  not  give  the 
patient  discomfort  and  threaten  the  pregnancy,  is  expectant.  But  when 
the  tumor  is  fixed  in  the  true  pelvis  an  effort  should  be  made,  with  the 
patient  occupying  the  knee-chest  position,  to  push  it  out  of  the  pelvic 
cavity.  Large  tumors  are  to  be  treated  by  abortion,  tapping,  or  ovari- 
otomy. The  first  is  generally  rejected,  and  the  second  is  only  applicable 
to  a  monocyst,  or  to  a  tumor  which  is  composed  chiefly  of  one  cyst. 
The  general  professional  sentiment  is  in  favor  of  ovariotomy  if  the 
tumor  be  large;  the  results  are  usually  good,  and  especially  if  the  opera- 
tion be  done  early  in  the  pregnancy. 

Ovariotomy  in  pregnancy  was  first  suggested  by  Merriman,  in  1817,  and  was 
first  successfully  done  by  Marion  Sims ;  the  operator,  however,  did  not  know 
before  the  operation  was  begun  that  the  patient  was  pregnant. 

Ovariotomy  in  pregnancy  has  been  done  by  Schroder  sixteen  times,  by  Ols- 
hausen twenty-six,  and  Tait,  1889,  in  thirty  cases,  in  all  seventy-two  cases,  without 
a  death. 

In  20  per  cent.1  of  cases  abortion  follows.     On  the  other  hand,  both  Flaischlen 

1  Zeitschrift  f.  GeburtshUlfe  und  Gynakologie,  1894. 


444  THE  PATHOLOGY  OF  PREGNANCY. 

and  Martin  have  each  operated  in  a  case  where  abortion  was  threatened,  and 
the  danger  disappeared  with  the  removal  of  the  tumor. 

Complication  of  labor  with  an  ovarian  tumor  occurred  in  the  Berlin  Frauen- 
Klinik  only  five  times  out  of  17,832  labors. 

DISEASES  OF  THE  BREASTS.  Occasionally  mastitis  is  seen  in  the  latter 
part  of  pregnancy,  the  disease  being  in  most  cases  probably  traumatic ; 
Schroder,  however,  speaks  of  its  occurrence  from  tumors  as  exceptional. 
The  treatment  is  not  modified  by  the  pregnant  condition,  nor  does  the 
former  have  any  disturbing  influence  upon  the  latter,  unless  very  high 
fever  occurs.  Malignant  disease  of  the  mammary  gland  usually  makes 
more  rapid  progress  during  pregnancy ;  hence  the  indication  for  removal 
of  the  diseased  structure  without  waiting  until  the  pregnancy  ends. 
According  to  Verneuil,  adenomata  of  the  breast  are  either  not  affected 
by  or  diminish  during  pregnancy. 

URINARY  DISORDERS.  Cystitis.  Inflammation  of  the  bladder  is 
occasionally  seen  in  the  pregnant  woman.  Predisposing  cause  is  given 
in  the  participation  of  the  bladder  in  the  congestion  of  the  uterus. 
Then  it  may  originate  from  a  posterior  displacement  of  the  uterus,  with 
consequent  retention  of  urine,  or  in  retention  from  another  cause,  and  the 
use  of  a  catheter,  perfect  antiseptic  precautions  not  being  observed. 

The  tenderness  of  the  bladder  and  the  presence  of  pus  in  the  urine 
make  the  diagnosis  easy.  There  cannot  be  a  cystitis  without  pus 
(Guyon).  The  treatment  will  be  rest,  warm  baths,  drinks  to  dilute 
the  urine — among  these  milk  is  probably  the  most  valuable ;  diu- 
retics, such  as  infusion  of  uva  ursi,  may  be  given.  Should  these 
means  fail,  washing  out  the  bladder  with  a  solution  of  boric  acid,  40  to 
1000  ;  salicylic  acid,  1  to  1000 ;  thymol,  or  potassic  permanganate,  1  to 
1000 ;  the  last  is  especially  commended  by  Vinay.  My  own  preference 
is  for  creolin,  ten  drops  to  a  pint;  of  course,  the  solution  or  mixture  (in 
the  case  of  the  creolin)  is  used  warm.  Hegar's  funnel  is  convenient. 

Diabetes  Mellitus.  This  disease  has  been  rarely1  observed  in  the 
pregnant  woman.  In  some  cases  it  .originates  during  pregnancy,  but  in 
others  it  antedates  gestation.  In  all  the  pregnancy  aggravates  the  dis- 
ease. Not  only  this,  but  the  latter  injuriously  affects  the  former,  the  preg- 
nancy in  fifty  per  cent,  of  cases  ending  by  abortion  or  premature  labor. 

The  treatment  of  the  disease  is  the  same  as  in  the  non-pregnant.  The 
question  of  arresting  the  pregnancy  is  undecided.  Fry2  takes  the  posi- 
tion that  a  woman  with  diabetes  should  not  marry,  and  regards  it  as 
questionable  whether  marriage  ought  to  be  permitted  in  case  of  strong 
hereditary  predisposition  to  the  disease. 

Nephritis.  Chronic  renal  disease  is  unfavorably  affected  by  the  preg- 
nancy, but  often  lessens  after  delivery.  In  regard  to  the  treatment  the 
subject  has  been  sufficiently  considered  under  the  head  of  albuminuria. 

TRAUMATISMS  IN  PREGNANCY.  Under  this  title  will  be  included 
accidental  injuries  and  surgical  operations. 

Many  instances  of  pregnant  women  having  undergone  severe  injuries 
without  the  gestation  being  arrested,  or  in  other  cases  without  the  loss 
of  life,  have  been  reported,  Fractures  of  the  lower  limbs,  of  the  pel- 

1  Duncan :    Transactions  of  London  Obstetrical  Society,  vol.  xxiv. 

2  Fry  :  Transactions  of  the  American  Gynecological  Society,  vol.  xvi. 


DISEASES  OF  THE  SEXUAL  ORGANS.  445 

vis,  and  even  of  the  vertebral  column  have  occurred,  and  the  preg- 
nancy gone  to  term.  In  one  instance  a  woman  seven  months  pregnant 
jumped  from  a  third-story  window  to  the  pavement,  breaking  her  legs 
and  her  arms,  yet  labor  took  place  at  the  normal  period.  In  this  con- 
nection the  question  as  to  the  delayed  repair  of  fractures  in  the  pregnant 
may  be  referred  to.  Miiller1  regards  the  question  as  still  an  open  one. 
He  speaks  of  the  frequently  made  assertion  that  fractures  of  the  upper 
limbs  heal  readily,  while  those  of  the  lower  limbs  do  not  consolidate 
until  after  labor. 

I  knew  of  a  case  in  which  a  fracture  of  the  femur  happening  to  a  woman  seven 
months  pregnant  did  not  unite  until  some  weeks  after  she  was  delivered,  and  then 
with  unusual  deformity.  The  doctors  who  treated  her  were  sued,  and  very  heavy 
damages  recovered  ;  but  the  verdict  was  set  aside. 

Dr.  R.  P.  Harris2  has  collected  twenty  cases  of  injuries  to  the  ab- 
dominal wall,  or  to  it  and  the  pregnant  uterus,  from  the  horns  of  ani- 
mals, and  only  seven  of  the  mothers  perished  and  eleven  of  the  children. 
Frequently  injuries  have  been  done  the  uterus  by  instruments  in  attempts 
to  procure  abortion,  the  instrument  penetrating  the  uterine  wall.  The 
uterus  has  been  injured  by  firearms  ;  in  rare  cases  a  bullet  passing  through 
its  wall  has  also  passed  through  the  body  of  the  child. 

The  most  remarkable  instance  of  a  minor  injury  to  the  foetus,  illustrating,  too, 
the  strang  migrations  of  a  needle,  has  been  reported  by  Behm.3  A  pregnant 
woman  accidentally  pushed  into  the  abdominal  wall  a  sewing-needle.  After  the 
birth  of  the  child  the  needle  was  found  in  its  knee. 

Amputation  of  the  .mammary  gland,  of  a  limb,  of  the  vaginal  cer- 
vix, disarticulation  of  joints,  ovariotomy,  herniotomy,  etc.,  have  been  done 
many  times  in  pregnant  women  without  the  gestation  being  disturbed  ; 
so,  too,  Emmet's  operation  for  lacerated  cervix. 

Griieniot4  has  taken  the  ground  that  a  surgical  operation  involving 
the  genital  zone  is  contra-indicated,  except  in  urgent  cases,  by  gestation. 
The  chief  conclusions  in  regard  to  traumatisms,  whether  accidental  or 
intentional,  given  by  Gu6niot  are  these  : 

1.  The  harmlessness  of  traumatism  in  pregnancy  is  not  governed  by  any  ab- 
solute law. 

2.  A  traumatism,  if  the  woman  has  no  morbid  predisposition,  she,  her  uterus, 
and  the  ovum  healthy,  is  generally  without  injurious  effect  upon  the  pregnancy. 

3.  If  gestation  be  complicated  with  a  pathological  condition,  such  as  abnor- 
mal irritability  of  the  uterus,  disease^  or  great  size  of  the  ovum,  albuminuria, 
etc.,  the  traumatism,  however  slight,  and  whatever  the  part  involved,  most  fre- 
quently causes  premature  expulsion  of  the  ovum. 

4.  Great  caution  is  advisable  in  performing  surgical  operations  during  preg- 
nancy. 

Sir  James  Paget5  states  that  while,  on  the  one  hand,  it  would  be 
mere  recklessness  to  operate  on  a  pregnant  woman  without  good  cause, 

1  Handbuch  der  Geburtshiilfe. 

2  Abdominal  and  uterine  tolerance  in   pregnant  women  under  severe  lacerated  and  other 
wounds  from  direct  violence,  1892. 

3  Quoted  by  Ahlfeld.  *  Annales  de  Gynecol.,  tome  vi. 
8  Clinical  Lectures  and  Essays. 


446  THE  PA THOLOG  Y  OF  PREGNANCY. 

yet  if  good  cause  for  operation  exists  she  may  be  treated  very  success- 
fully. 

Tiffany,  from  a  consideration1  of  the  relations  between  pregnancy  and 
operative  surgery,  presents  ten  conclusions,  the  first  and  last  of  which 
are  the  following : 

Pregnancy  is  a  physiological  condition,  and  does  not  centra-indicate  a  surgical 
operation. 

When  a  surgical  operation  upon  a  pregnant  woman  is  under  consideration  the 
functions  of  all  the  patient's  organs  must  be  carefully  investigated  and  regu- 
lated. An  operation  then  conducted  antiseptically  may  be  expected  to  result  as 
though  pregnancy  were  not  present. 

Winckel,  after  recounting  many  cases  of  serious  injury  occurring  to 
pregnant  women,  or  important  surgical  operations,  several  occurring  in 
his  own  practice,  performed  upon  them,  gestation  usually  continuing 
the  normal  period,  concludes  that  direct  wounds  of  the  uterus  and  its 
contents  in  pregnancy  do  not  necessarily  cause  the  expulsion  of  the 
foetus ;  indeed,  that  this  is  not  the  usual  consequence,  and,  therefore,  if 
there  is  a  necessity  for  operating,  as  favorable  results  may  be  expected 
as  if  the  subject  were  not  pregnant. 

Miiller  refers  to  the  improvements  of  modern  surgery,  the  great  fac- 
tors of  which  are  narcosis,  better  technique,  and  antisepsis,  as  widening 
the  boundaries  of  the  operative  field  in  pregnancy. 

1  Maryland  Medical  Journal,  January,  1889. 


CHAPTER    VI. 

DISEASES    OF   THE    OVUM — DEATH    OF   THE    FCETUS — ABORTION — 
PREMATURE    LABOR. 

THE  term  ovum  includes  the  membranes — decidua,  chorion,  and 
amnion — which  compose  the  foetal  sac,  the  embryo  or  foetus,  the  pla- 
centa, and  cord. 

DECIDUAL  ENDOMETRITIS.  Inflammation  of  the  decidua  is  very 
frequent,  and  in  many  instances  causes  abortion.  The  decidua  fur- 
nishes,1 as  Martin  Saint-Ange  expresses  it,  an  incubating  chamber  for 
the  impregnated  ovule,  and  if  the  former  become  diseased  injury  to  the 
latter  is  very  likely  to  result.  Decidual  endometritis  may  be  either 
acute  or  chronic.  The  former  is  caused  by  acute  febrile  diseases,  is 
especially  characterized  by  hemorrhage,  and  its  usual  consequence  is 
miscarriage. 

Four  varieties  of  chronic  decidual  endometritis  have  been  described. 

1.  Diffuse  Decidual  Endometritis.  This  usually  affects  the  parietal, 
or  uterine  decidua,  decidua  vera,  rather  than  the  decidua  reflexa,  the 
ovular  decidua ;  it  is  characterized  by  the  thickening  of  the  decidua 
from  proliferation  of  the  decidual  cells  and  development  of  the  con- 
nective tissue ;  subjacent  muscular  fibres  may  also  be  involved  iu  the 
hyperplasia. 

'2.  Polypoid  Decidual  Endometritis.  Here,  with  chronic  prolifera- 
tion and  thickening  of  the  decidua  vera,  polypoid  growths  appear ; 
these  are  about  three-fourths  of  an  inch  in  height,  and  are  broad-based 
and  irregular  in  form.  If  polypoid  endometritis  occur  early,  the  inflam- 
matory process  readily  extends  to  the  chorial  villi,  with  resulting  atrophy 
of  the  ovum,  and  abortion;  upon  the  aborted  ova  the  manifestations 
of  diffuse  and  of  polypoid  decidual  endometritis  may  be  seen.2 

3.  Cystic  Decidual  Endometritis.     In  this  form  of  decidual  endome- 
tritis the  inflammation  involves  the  glands  of  the  mucous  membrane  ; 
the  intra-glandular  connective  tissue  is  increased  and  the  membrane  is 
swelled  ;  hence,  obstruction  of  the  gland  ducts  and  retention  of  gland- 
ular secretion  with  the  formation  of  cysts.     In  other  words,  they  are 
retention-cysts. 

4.  Catarrhal  Decidual  Endometritis.      The  characteristic  indication 
of  this  disease  is  the  discharge  from  time  to  time  of  a  watery  fluid  from 
the  uterus,  constituting  what  is  generally  known  as  hydrorrhaea  gravi- 
darum.     The  disease  is  more  frequent  in  multigravidee  than  in  primi- 
gravidae ;  it  may  occur  as  early  as  the  third   month,  but  usually  not 
until  the  late  months  of  pregnancy.     The  fluid  is  albuminous  and  gen- 
erally yellowish,  and  at  times  may  contain  blood.     The  probability 

1  Iconqgraphie  Pathologique  de  l'O3uf  Humain  Feconde. 

2  Archiv  fur  Gynakologie,  1885.    Breus  :  Ueber  cystose  Degeneration  der  Decidua  vera. 


448 


THE  PATHOLOGY  OF  PREGNANCY. 

FIG.  176. 


POLYPOID  ENDOMETRITIS. 

a.  Fine  apertures  of  the  glands ;   6.  larger  apertures  of  the  glands ;   c.  protuberances 
of  polypi.    (ViKCHOw.) 

seems  to  be  that  its  chief  source  at  least  is  the  uterine  glands.  At  first 
it  appears  between  the  decidua  vera  and  the  decidua  reflexa,  but  after 
these  are  united  the  transudation  must  be  between  the  chorion  and  the 
reflexa ;  the  occasional  presence  of  blood  in  the  discharge  from  the  uterus 
is  probably  explained  as  resulting  from  the  fluid,  after  passing  by  partial 
rupture  of  the  decidua  to  the  outside  of  the  ovum  in  its  descent,  causing 
detachment  of  a  part  of  the  decidua  from  the  uterus.  Many  of  the 
cases  of  supposed  rupture  of  the  membranes,  days  or  weeks  before  labor, 
are  really  examples  of  hydrorrhoea,  a  discharge  of  false  waters,  not  of  the 
amnial  liquor,  occurring.  Slight  pains  usually  accompany  the  dis- 
charge, and  in  most  cases  it  is  repeated  several  times  before  pregnancy 
ends.  Premature  labor  very  rarely  follows  hydrorrhoea,  but  its  possible 
occurrence  indicates  that  the  patient  thus  affected,  especially  if  there  be 
any  uterine  contractions,  should  remain  lying  down,  and  in  some  cases  a 
rectal  injection  of  twenty  to  thirty  drops  of  laudanum  will  be  advisable. 
The  symptoms  of  decidual  endometritis  are  often  uncertain.  But  in 
some  cases  the  discharge,  occasionally  bloody,  and  the  sensitiveness  of 
the  uterus  to  abdominal  pressure  point  to  the  disease.  J.  Veit  regards 
hyperemesis  as  often  dependent  upon  the  disease. 

He  states  that  in  consequence  of  the  inflamed  condition  in  the  organ  there  is 
an  increased  irritability  of  the  uterine  nerves,  and  hence  existence  of  reflex 
neuroses.  Jaggard  has  reported1  a  case  of  obstinate  vomiting  caused  by  decidual 
endometritis. 

ATROPHY  OF  THE  DECIDUA.  This  may  affect  the  decidua  vera,  or 
the  decidua  serotina  and  reflexa.  In  hypoplasia  the  development  of  the 

1  Journal  of  the  American  Medical  Association,  1889. 


DISEASES  OF  THE  OVUM.  449 

decidua  is  imperfect.  These  anomalies  of  the  vera  are  less  important 
as  causes  of  abortion  than  if  they  affect  the  serotina  and  the  reflexa. 

In  general,  diseases  of  the  decidua  do  not  furnish  so  much  thera- 
peutic indication  during  pregnancy,  as  after  its  interruption  they  do  for 
treatment  of  the  endometrium  in  order  to  prevent  a  recurrence  of  the 
accidents  in  a  new  pregnancy. 

ANOMALIES  OF  THE  PLACENTA.  Anomalies  of  Size  and  of  Form. 
The  relation  between  the  weight  of  the  placenta  and  the  child  has  been 
stated  on  page  129.  The  placenta  is  abnormally  large  in  polyhydram- 
nios,  in  syphilis,  and  also  in  the  case  of  a  macerated  foetus.  The  placenta, 
too,  may  grow  after  the  death  of  the  fcetus. 

The  anomalies  in  the  form  of  the  placenta  are  many.  The  placenta 
succenturiata,  or  subsidiary  placenta,  has  already  been  mentioned.  The 
union  between  a  placenta  succenturiata  with  the  chief  placenta  is  usually 
by  branches  of  vessels ;  but  if  true  placental  tissue  makes  the  connec- 
tion, the  horseshoe  placenta  results.  Should  the  subsidiary  placenta 
have  the  shape  of  a  half-moon,  its  concave  surface  turned  to  the  chief 
placenta,  the  placental  tissue  will  enclose  a  space  like  a  window,  placenta 
fenestrata.  Placenta  marginata  shows  at  its  foetal  surface  a  fibrinous 
ring,  which  extends  from  one  to  two  centimetres  from  the  villous  tissue  ; 
the  amnion  arises  from  the  inner  margin  of  this  ring.  Barnes  has  ex- 
plained this  form  of  the  placenta  as  originating  from  the  chorion  fron- 
dosum,  occupying  only  the  middle  of  the  placenta  and  leaving  the 
marginal  part  bare.  Klein,  however,1  regards  it  as  resulting  from 
thickening  of  the  border  of  the  reflexa  consequent  upon  inflammatory 
changes — decidual  endometritis. 

Placenta  Circumvallata  originates  thus :  If2  the  union  of  the  reflexa 
and  vera  is  prevented  by  hypersecretion  of  the  latter  or  from  endome- 
tritic  processes,  the  site  of  placental  attachment  is  small ;  abortion  not 
occurring,  there  is  formed  either  a  very  thick  placenta,  or  it  grows  so 
that  it  forms  above  the  reflexa  and  vera  an  exuberant,  mushroom-like 
development. 

Structural  Anomalies  of  the  Placenta.  Cysts  varying  in  size  from 
that  of  a  pea  to  that  of  a  nut  may  be  found  upon  the  inner  surface  of 
the  placenta ;  they  usually  contain  a  thin,  yellowish  fluid. 

Calcareous  concretions  are  not  uncommon.  Chemical  analysis  shows 
the  deposit  to  be  composed  of  carbonate  and  phosphate  of  lime ;  Robin 
found  also  phosphate  of  magnesia.  These  calcareous  formations  occur 
both  in  the  maternal  and  foetal  portions  of  the  placenta. 

It  is  usually  stated  that  such  deposits  are  without  any  importance.  But  recently, 
however,  in  some  cases  of  premature  detachment  of  the  normally  situated  pla- 
centa the  deposits  were  abundant,  and  the  not  improbable  suggestion  has  been 
made  that  they  have  contributed  to  the  untimely  separation. 

Dr.  Thomas  G-.  Maghee,  of  Rawlins,  Oregon,  sent  me,  a  year  and  a  half  ago, 
a  most  remarkable  calcareous  placenta.  According  to  his  description,  "  50  per 
cent,  of  the  bulk  of  the  placenta  was  calcareous  m  atter  in  flakes,  scales,  and 
irregular  angular  concretions.  The  placenta  measured  seven  inches  in  diameter 
and  weighed  ten  ounces ;  the  cord  normal.  The  parents  were  healthy.  The 
child  died  three  days  before  labor ;  it  was  a  well-formed,  well-developed  female, 
weighing  nine  pounds  and  four  ounces." 

1  Hofmoier :  Die  menschliche  Placenta,  1890.  8  Kaltenbach. 

29 


450  THE  PATHOLOGY  OF  PREGNANCY. 

Unfortunately,  there  has  been  no  complete  and  satisfactory  examination  of 
this  remarkable  specimen ;  but  I  hope  there  will  be  one  made  soon. 

Myxoma  of  the  Placenta  originates  in  myxomatotis  degeneration  of 
some  of  the  villi  after  the  placenta  is  formed.  In  some  cases  this 
degeneration  is  so  general  that  the  foetus  perishes ;  but  in  others  suffi- 
cient of  the  placenta  remains  unchanged  for  the  needs  of  the  foetus,  and 
it  is  born  living  at  term. 

Fibrous  Myxoma  originates,  according  to  Virchow,  in  a  fibrous 
degeneration  of  the  mucous  substance  of  individual  villi.  It  appears 
in  the  form  of  thick,  compact  nodules;  according  to  the  extent  of  their 
formation  will  be  the  effect  upon  the  life  of  the  foetus :  if  this  extent  be 
great,  it  perishes. 

INFLAMMATION.  White  Infarcts  of  the  Placenta.  Inflammation  of  the 
maternal  portion  of  the  placenta  originates  in  endometritis  in  pregnancy. 
It  is,  according  to  Hegar  and  Maier,  a  process  of  proliferation  of  cells, 
with  subsequent  contraction,  causing  atrophy  of  the  villi.  The  foetus 
is  imperfectly  developed,  or  abortion  occurs.  It  is  asserted  that  if  the 
inflammation  affects  the  serotina  firm  adhesions  to  the  uterus  may  result, 
requiring  artificial  detachment  of  the  placenta. 

The  so-called  white  infarcts,  or  fibrinous  wedges,  are  described  as 
"somewhat  round  or  oval,  whitish-yellow,  hardish  parts  of  varying 
size,  even  to  several  centimetres,  that  in  different  numbers  are  situated 
most  thickly  under  the  amnion."  They  have  been  attributed  to  a  coag- 
ulation-necrosis caused  by  periarteritis  ;  by  others  the  starting-point  is 
in  changes  in  the  decidua — hyaline  degeneration  of  the  decidua  and 
consequent  necrosis  of  the  villi.  Microscopically  they  are  shown  to 
consist  for  the  most  part  of  coagulated  fibrin,  in  which  are  included 
fragments  of  decidual  cells,  blood  extravasates,  and  atrophied  villi. 
Their  connection  with  nephritis  has  been  frequently  observed,  and 
Kaltenbach  mentions  his  having  found  the  largest  placental  infarcts 
more  frequently  in  the  placentae  of  women  suffering  with  albuminuria 
than  in  the  case  of  nou-albuminurics. 

Small  decidual  infarcts  are  common,  and  have  no  unfavorable  results 
so  long  as  the  villi  are  not  encroached  upon. 

SYPHILITIC  PLACENTA.  The  syphilitic  placenta  is  larger  and  heavier 
than  the  normal  placenta ;  its  consistence,  too,  is  often  greater.  The 
following  are  the  conclusions  given  by  Zilles  in  his  monograph1  upon 
the  subject : 

1.  There  is  such  a  disease  as  placental  syphilis,  and  in  many  cases  it  can  be 
diagnosticated  by  the  experienced  eye  from  macroscopic  appearances. 

2.  Placental  syphilis  is  generally,  but  not  always  as  stated  by  Fraenkel,  asso- 
ciated with  foetal  syphilis.    The  mother  may  be  infected  and  the  child  healthy ; 
these  are  usually  cases  where  she  becomes  infected  during  pregnancy. 

3.  The  placenta  may  be  affected  throughout  its  entire  thickness,  or  only  either 
the  maternal  or  foetal  portion,     (a)  When  the  mother  is  infected  by  the  fecundat- 
ing coition,  we  find,  with  foetal  syphilis,  the  placenta  more  or  less  affected  in  all 
its  parts;  the  cord,  too,  is  usually  diseased.     (6)  If  the  semen  alone  carry  the 
syphilitic  virus,  and  the  mother  is  not  infected,  we  have   foetal  syphilis,  and 
usually  only  in  addition  syphilis  of  the  foetal  placenta  and  of  the  cord.     But  it 

1  Studien  liber  Erkrankungen  der  Placenta  und  der  Nabelschnur  bedingt  durch  Syphilis,  von 
Rudolf  Zilles.    Tubingen,  1886. 


DISEASES  OF  THE  OVUM.  451 

may  extend  to  the  maternal  placenta,  and  then  the  mother  is  infected.  (<••)  In 
case  the  mother  he  infected  a  short  time  before  conception,  the  disease  not  yet 
constitutional,  and  the  impregnation  by  a  healthy  man,  if  antisyphilitic  treatment 
be  employed,  a  healthy  child  may  be  born.  In  such  cases  the  maternal  placenta 
alone  is  usually  affected,  (d)  If  the  woman  was  infected  long  before  concep- 
tion, usually  the  maternal  placenta  only  is  affected ;  but  the  process  may  extend 
to  the  foetal  placenta  and  to  the  foetus,  (e)  When  the  mother  is  impregnated  by 
a  healthy  man  and  becomes  infected  during  gestation,  the  maternal  placenta  is 
invariably  affected,  and  usually  there  is  immunity  for  the  foetus. 

The  placenta  cannot  be  free  from  disease  if  the  mother  be  syphilitic,  unless  the 
infection  occurred  shortly  before  labor. 

4.  That  a  woman  may  be  infected  by  the  passage  of  a  syphilitic  foetus  through 
the  birth-canal,  and  vice  versa,  has  not  been  proved. 

5.  Experience  teaches  that  during  the  first  few  years  after  syphilis  has  been 
acquired,  and  the  disease  not  treated,  the  children  usually  die  in  the  uterus,  or 
are  non-viable  when  born.     Suitable  mercurial  treatment  may  subdue  the  hered- 
itary power  of  syphilis  or  make  it  latent  for  a  number  of  years ;  and  this  is  true, 
no  matter  what  the  stage  of  the  disease.     If  the  disease  remain  in  a  latent  con- 
dition in  some  of  the  organs,  the  effect  of  treatment  may  be  that  for  a  time 
healthy  children  are  born,  but  later  syphilitic  children. 

TUBERCULOSIS  OF  THE  PLACENTA.  Lehman,1  of  Berlin,  has  reported 
a  case  of  tuberculosis  of  the  placenta.  The  placenta  was  that  of  a  woman 
who  died  from  miliary  tuberculosis  while  pregnant ;  the  intestines  and 
peritoneum  did  not  participate  in  the  disease. 

DISEASE  or  THE  CHORION.  Hydatidiform,  or  myxomatous  de- 
generation of  the  chorial  villi,  has  been  considered  in  its  partial  mani- 
festation, myxomatous  degeneration  of  the  placenta,  and  there  is  here  to 
be  presented  the  graver  variety  which,  beginning  before  the  placenta  is 
formed,  involves  all  the  chorial  villi.  The  disease  results  in  the  for- 
mation of  a  mass  known  as  a  vesicular  mole.  This  mass  is  a  con- 
glomerate of  a  vast  number  of  vesicles,  varying  in  size  from  a  hemp- 
seed  to  a  cherry,  inclosed  in  thickened  decidua;  it  may  be  as  large  as  a 
child's  head,  and  weigh  several  pounds.  After  two  months  the  mass  is 
no  longer  inclosed  in  the  sac,  but  this  sac  is  torn  at  different  parts  and 
the  growths  project  from  the  rents. 

From  the  opened  cyst  a  watery  fluid,  containing  in  addition  to  albumin 
mucin,  escapes. 

In  rare  cases  the  entire  mass  has  been  expelled  inclosed  in  a  sac,  the 
decidua,  and  this  had  to  be  opened  to  see  the  peculiar  formation.  In 
the  centre  of  the  degenerated  mass  there  is  usually  a  cavity  found ;  but 
if  the  myxomatous  change  began  early,  that  is,  before  the  formation  of 
the  placenta,  and  all  the  chorial  villi  were  affected,  the  nutrition  of  the 
embryo  has  been  so  interfered  with  that  death  resulted,  and  it  has  under- 
gone solution;  a  little  fluid  may* be  found  in  the  cavity,  and  also,  pos- 
sibly, the  remains  of  a  part  of  the  umbilical  cord.  In  some  instances 
the  amnial  cavity  has  disappeared,  but  there  is  almost  always  found  in 
such  case  a  soft,  yellowish,  granular,  and  spongy  tissue  occupying  its 
space.  The  death  of  the  embryo  is  by  most  regarded  as  the  consequence, 
not  the  cause  of  the  disease.  When  the  disease  occurs  later,  involving 
only  a  portion  of  the  placenta,  it  may  not  be  discovered  until  after  the 
birth  of  a  well-developed  child,  and  the  expulsion  of  the  placenta,  which 
upon  examination  shows  the  altered  structure. 

1  Centralblatt  f.  Gynakol.,  November  18, 1893. 


452 


THE  PATHOLOGY  OF  PREGNANCY 


In  rare  instances  a  destructive  mole-formation  has  been  observed.  In  this  the 
degenerated  villi  perforate  the  decidua,  invade  the  uterine  walls,  entering  veins, 
and  reach  to  the  serous  covering  of  the  uterus ;  the  patients  generally  perish 
from  hemorrhage  or  peritonitis,  and  it  is  only  after  death  that  the  true  condition 
has  been  revealed. 


FIG.  178. 


BRANCH  OF  HYDATIGENOUS  PLACENTA,  AS  SEEN  BY 
THE  NAKED  EYE.    (ERCOLANI.) 


HYDATIDIFORM  DEGENERATION  OF 
THE  CHORION. 


The  normal  villi  of  the  chorion,  as  shown  by  Virchow,  have  enter- 
ing into  them  the  same  tissue  as  that  which  forms  the  so-called  Whar- 
ton's  jelly  of  the  umbilical  cord.  Each  villas  has  an  external  epithelial 
covering,  but  the  framework,  the  body  of  the  organ,  is  formed  of  mucous 
issue.  Hyperplasia  of  this  tissue  is  the  essential  fact  in  myxomatous 
degeneration  of  the  chorial  villi.  With  the  increase  in  volume  of  a 
villus  the  more  it  presents  the  appearance  of  mucous  tissue.  The  pedicle 
of  the  apparent  vesicle  is  identical  with  Wharton's  jelly.  The  vessels 
of  the  villi  are  usually  obliterated ;  nevertheless,  capillary  vessels  are 
sometimes  found  in  the  external  layers,  especially  when  a  part  only  of 
the  chorion  is  degenerated,  and  the  fcetus  is  viable. 


DISEASES  OF  THE  OVUM.  453 

In  rare  instances  there  is  a  double  pregnancy,  one  ovum  remaining 
healthy  and  the  other  changed  into  a  vesicular  mole.  See  Fig.  179. 

ETIOLOGY.  This  is  uncertain.  In  one  case,  that  of  Schroder,  there 
was  a  large  myoma  of  the  uterus ;  in  another  there  was  a  tumor  of  each 
ovary,  and  in  several  renal  disease  was  present  with  albuminuria,  the 
albumen  disappearing  after  the  mole  was  discharged.  Schramm1  refers 
to  the  affection  occurring  more  frequently  in  pluriparse  who  are  weak, 
ansemic,  and  suffering  from  cardiac  disease. 

The  disease  is  not  frequent.  Madame  Boivin  saw  but  one  case  in 
20,375  deliveries. 

Two  cases  in  which  malignant  disease  of  the  uterus  followed  have 
been  observed  by  Kaltenbach  and  Lohlein,2  originating,  it  was  sup- 
posed, from  retention  of  some  of  the  degenerated  chorial  villi. 

FIG.  179. 


TWIN  PREGNANCY — MOLAR  AND  NORMAL.    (KALTENBACH.) 

DIAGNOSIS.  Depaul  mentioned  three  important  signs.  1.  A  more 
rapid  development  of  the  abdornen  than  occurs  in  normal  pregnancy. 
In  one  of  his  patients  the  uterus  was  four  fingers'  breadth  above  the 
umbilicus  at  four  mouths.  2.  Attacks  of  uterine  hemorrhage.  This 
symptom  has  occurred  as  early  as  the  forty-fifth  day,  and  been  delayed 
as  late  as  the  fourteenth  month.  Discharges  of  blood  may,  in  some 
cases,  alternate  with  watery  discharges.  3.  The  expulsion  of  separate 
vesicles,  or  of  branches  of  vesicles.  Of  course,  this  sign  is  conclusive. 
The  pregnancy  rarely  goes  to  term ;  yet,  in  the  32  cases  collected  by 
Boivin,  in  each  of  three  it  lasted  until  9  months ;  in  three  others  to  10 

i  Centralblatt  f.  Gynakol.,  1893,  No.  4.  2  Centralblatt  f.  Gynakol. ,  1893. 


454  THE  PATHOLOGY  OF  PREGNANCY. 

months,  while  one  was  not  delivered  until  11  months,  and  another  at  14 
months.  The  danger  to  the  .mother  is  from  the  exhaustion  caused  by 
repeated  hemorrhages,  or  a  single  sudden  and  large  hemorrhage  may 
prove  immediately  fatal.  The  foetus  in  almost  all  eases  dies.  Yet  there 
are  instances  in  which  an  "  hydatid  "  mass  has  been  expelled,  and  the 
pregnancy  continued  to  term,  when  a  healthy  child  was  born.  Such 
cases  were  probably  instances  of  a  twin  pregnancy  in  which  the  myxo- 
matous  degeneration  affected  one  ovum,  the  one  that  was  discharged, 
while  the  other  remained  healthy. 

TREATMENT.  No  active  treatment  is  indicated  unless  hemorrhage 
occurs.  If  this  be  slight,  rest,  cold  drinks,  and  an  opiate  may  be  suffi- 
cient ;  but  if  it  be  severe,  the  tampon  should  be  at  once  employed. 
Even  if  the  fact  of  myxomatous  degeneration  be  proved  by  the  ex- 
pulsion of  hydatids,  it  does  not  follow  that  the  uterus  must  be  at 
once  emptied.1  The  dominant  fact  which  guides  the  treatment  is  the 
hemorrhage.  If  this  persists,  if  it  is  grave,  and  only  temporarily  re- 
strained by  the  tampon,  then  dilate  the  os  uteri,  and  remove  the  contents 
of  the  uterus  with  hands  or  forceps,  or  dull  curette,  and  secure  uterine 
ha3mostasis  by  exciting  uterine  contraction  mechanically,  or  by  ergot,  or 
by  electricity;  or,  if  these  fail,  use  intra-uterine  injections  of  hot  water, 
or  apply  astringent  solutions  to  the  interior  of  the  uterus. 

ANOMALIES  OF  THE  CORD.  Some  of  these  have  already  been  men- 
tioned, such  as  length  of  cord,  quantity  of  Wharton's  jelly,  and  false  knots. 

COILS.  One  or  more  loops  or  "circulars"  of  the  cord  about  the 
infant  or  one  or  more  of  its  members  occurs  in  many  cases  ;  the  most 
frequent  are  those  in  which  the  cord  encircles  the  neck  once  or  oftener ; 
in  some  cases  an  upper  or  lower  limb  may  be  caught  in  a  coil.  La  Motte 
gives  a  case  in  which  the  cord  passed  around  the  neck,  then  over  the 
chest  like  a  scarf,  and  under  the  axilla,  and  again  around  the  neck. 
Usually  no  injurious  consequences  follow,  but  in  some  instances,  when 
the  neck  is  encircled,  the  loop  may  become  so  tight  that  the  circulation 
in  the  cord,  or  in  the  vessels  of  the  neck,  may  be  interfered  with,  and 
the  foetus  dies.  "  If  the  compression  continues  after  death,  the  neck 
may  be  so  thin  that  it  is  almost  amputated."  Amputation  of  one  of 
the  limbs  may  result  from  a  tight  coil  of  the  cord  around  it,  if  continued 
for  some  time,  even  though  the  foetus  be  living.  Dole>is2  has  narrated 
a  case  in  which  the  labor  was  protracted  in  consequence  of  the  cord 
forming  a  double  coil  about  the  lower  limbs  of  the  foetus  at  the  ankles ; 
hence  the  cord  was  much  shortened,  and  the  fcetus,  presenting  by  the 
vertex,  was  as  it  were  suspended  by  the  feet. 

This  case  illustrates  one  of  the  dangers  that  arise  when  the  cord  is 
coiled  around  the  foetus,  relative  shortness,  which  of  course  may  cause 
the  same  difficulty  in  labor  as  absolute  shortness  does. 

It  is  possible,  in  some  very  rare  cases,  if  the  abdominal  and  the 
uterine  walls  are  thin,  to  feel  the  pulsating  cord  when  it  encircles  the 
body.  Schatz3  claims  that  the  diagnosis  of  the  cord  encircling  the  neck 

i  All  the  world  knows,  remarked  Depaul,  that  the  celebrated  Beclard  was  the  result  of  a  hyda- 
tidiform  pregnancy.  The  possibility  of  a  viable  child  being  born,  therefore,  is  the  reason  for  ab- 
staining from  active  interference  in  case  of  this  disease,  unless  symptoms  demand  such  interference. 

-  Archives  de  Tocologie,  1882. 

*  Revue  Medico-chirurgicale  des  Maladies  des  Femmes,  1885. 


DISEASES  OF  THE  OVUM. 


455 


can  be  made  during  pregnancy  by  auscultation  ;  at  first,  moderate  pres- 
sure with  the  stethoscope  is  made  at  the  part  corresponding  with  the 
depression  of  the  neck,  and  the  pulsations  of  the  foetal  heart  are  normal 
in  frequency;  but  when  strong  pressure  is  made  their  frequency  is  less- 
ened to  one-half. 

KNOTS.  In  one  out  of  two  hundred  infants  there  will  be  found  at 
birth  one  or  more  knots  in  the  umbilical  cord.  They  result  from  the 
fetus  passing  through  a  loop  of  the  cord,  and  according  to  most  authori- 
ties may  be  formed  in  pregnancy  or  during  labor ;  Read,1  however, 
asserts  that  they  cannot  be  formed  except  by  the  passage  of  the  child 
through  the  lower  portion  of  the  uterus,  for  a  loop  must  fall  to  the 
vicinity  of  the  os,  it  cannot  remain  in  any  other  part  of  the  uterus,  and 
hence  they  can  be  formed  only  during  labor ;  but  this  view  is  not  gen- 


FiG.  180. 


FIG.  181. 


KNOT  IN  THE  STAGE  OF  FORMATION. 
P.    PLACENTAL  END. 


As  IT  WAS  FOUND  AT  BIRTH. 


erally  accepted.  Admitting  the  formation  of  knots  in  pregnancy,  it  is 
exceptional  for  the  vessels  to  be  so  constricted  as  to  interfere  with  the 
circulation  of  blood.  Depaul  has  found  in  one  instance  five  knots  in 
the  cord,  quite  near  together,  but  the  fetus  was  living  and  well  nour- 
ished. On  the  other  hand,  Martin  Saint-Ange  has  seen  death  of  the 
fetus  result  from  a  single  knot,  and  many  similar  cases  have  been  re- 
ported. Great  length  of  the  cord  predisposes  to  this  accident,  and  a 
relatively  great  size  of  the  uterus  facilitates  its  occurrence  in  pregnancy. 

1  American  Journal  of  the  Medical  Sciences,  October,  1861. 


456  THE  PATHOLOGY  OF  PREGNANCY. 

The  knot  is  sometimes  double,  as  in  a  case  observed  by  Dr.  George  H. 
Lyman,  of  Boston.  Read  gives  the  representations1  of  the  successive 
stages  in  the  formation  of  the  knot  in  Ly man's  case.  (See  Figs.  180, 
181,  and  182.) 

EXCESSIVE  TORSION.  Twisting  of  the  cord  upon  its  axis  generally 
occurs,  according  to  Spiegelberg,  in  the  second  half  of  pregnancy,  espe- 
cially in  the  seventh  lunar  month.  He  refers  to  torsions  as  u  praBmor- 
tal"  and  "  postmortal."  The  first  are  caused  by  the  active  movements 
of  the  foetus,  or  by  a  severe  fall  received  by  the  mother.  Wiuckel 
suggests  that  the  movements  of  one  of  the  two  foetuses  contained  in  a 
single  amnion  may  cause  twisting  of  the  cord  of  the  other.  The  "  post- 
mortal"  torsions  are  caused  by  the  movements  of  the  mother.  Dancing 
is  mentioned  by  Kormann  as  a  cause  of  torsions  of  the  cord.  They 
occur  more  frequently  in  male  than  in  female  foetuses,  the  proportion 
being  13  to  9.  Excessive  movements  of  the  fetus,  causing  torsions  of 
the  cord,  were  attributed  by  Billi  (quoted  by  Hecker)  to  disease  of  the 
brain.  The  facility  of  active  and  of  passive  movements,  too,  in  the 
foetus  of  the  multigravida  being  greater  than  in  the  primigravida,  these 
torsions  are  more  frequent  in  the  former.  It  is  said  that  a  division  of 
the  cord  may  be  caused  in  a  short,  tense  cord  by  twisting,  it  being  thus 
separated  from  the  foetus,  so  that  the  latter  is  unattached  in  the  uterine 
cavity.  The  torsions  are  mcst  numerous  in  the  vicinity  of  the  umbilicus, 
and  next  at  the  attachment  of  the  cord  to  the  placenta.  Torsions  of 
the  cord  may  cause  occlusion  of  its  vessels,  or  only  stenosis.  Death  of 
the  foetus  follows  occlusion  or  great  stenosis.  In  some  instances  tine 
thrombi  are  found  in  the  vessels  ;  these  indicate  that  the  torsions  occurred 
suddenly.  Fritsch  has  observed  that  in  some  cases  torsions  occur  in 
successive  pregnancies. 

I  have  seen  a  case  in  which  there  were  forty-six  twists  in  the  cord ; 
the  foetus  had  died  in  the  seventh  month,  and  was  macerated.  A  re- 
markable illustration  of  very  numerous  twists  of  the  cord  is  shown  in 
Fig.  83. 

Narrowing  of  the  vessels  may  occur  independently  of  torsions.  These  stenoses 
are  usually  found  in  the  vein  near  its  placental  end ;  "  they  were  first  observed  by 
Oedmanson  and  Winckel,  and  their  anatomical  description  given  by  Birch- 
Hirschfeld."  They  have  been  described  as  sharply  defined  proliferations  of  the 
intima,  partly  of  fusiform,  partly  of  round  cells,  and  forming  a  fibrillated  tissue, 
as  a  granular  matrix  with  oval  and  globular  nuclei.  Beginning  in  the  intima,  the 
adventitia  becomes  affected  ultimately,  and  shows  an  accumulation  of  lymphoid 
elements.  Birch-Hirschfeld  found  circumscribed  stenoses  involving  the  intima 
of  the  arteries  in  the  vicinity  of  the  navel  and  of  the  placenta ;  he  regards  them 
as  resulting  from  syphilis,  stating  that  the  microscopical  examination  agrees  in 
every  particular  with  those  changes  which  Heubner  described  as  syphilis  of  the 
vessels  of  the  brain.  According  to  Spaeth,  atheromatous  changes  may  occur  in 
the  arteries.  Stenosis  may  be  the  consequence  of  periphlebitis,  according  to 
Hyrtl.  Cysts  found  in  the  cord  are  remnants  of  the  urachus  lined  with  epithe- 
lium. 

Martin  Saint- Ange2  narrates  a  case  of  a  dead  foetus  being  expelled  at  seven 
months,  the  death  caused  by  complete  strangulation  of  the  cord  lying  between 
the  legs,  which  crossed  each  other  and  were  firmly  applied  together  by  a  convul- 
sive condition. 

1  Charpentler  in  using  these  illustrations  has  substituted  Leyman  for  Lyman. 

2  Op.  cit. 


DISEASES  OF  THE  OVUM.  457 

ANOMALIES  OF  THE  AMNION  AND  OF  THE  AMNIAL  LIQUOR.  The 
question  as  to  inflammation  of  the  amnion,  amniotitis,  is  undecided. 
The  formation  of  amniotie  bands,  resulting  in  amputation  of  foetal  mem- 
bers, or  in  the  production  of  foetal  malformations  and  adhesions  be- 
tween the  amnion  and  different  parts  of  the  foetal  surface,  seems  to  indi- 
cate that  inflammation  of  this  membrane  does  occur.  According  to 
some,  acute  polyhydramnios  is  the  consequence  of  inflammation  of  the 
foetal  membranes ;  this  was  the  theory  taught  by  Mercier  more  than 
fifty  years  ago. 

The  narrow  space  which  the  foetus  occupies  prevents  its  proper  development. 
Certain  deformities,  such  as  talipes  valgus  and  t.  varus,  occur  more  frequently 
in  connection  with  scanty  amnial  liquor — so,  too,  some  forms  of  single  mon- 
strosity, as  symmelian  and  syrenian. 

Dareste1  has  shown  the  important  connection  between  certain  fcetal 
anomalies  and  the  condition  of  the  amnion.  The  formation  of  amnial 
bands  may  result  from  oligohydramnios — that  is,  deficiency  of  the 
amnial  liquor — as  follows  :  The  amnion  is  in  contact  with  parts  of  the 
foetus,  not  kept  separate  by  fluid,  and  adhesions  result ;  but  with  in- 
crease of  fluid  these  adhesions  are  stretched,  and  thus  cords  or  bands  are 
formed.  Another  result  of  deficiency  of  amuial  liquor  is  superficial 
adhesions  between  the  members  of  the  body.2 

POLYHYDRAMNIOS.  The  most  frequent  anomaly  relating  to  the 
amnion  and  its  liquor  is  that  which  consists  in  an  excessive  production 
of  amnial  fluid,  incorrectly  designated  as  hydramnios  or  hydramnion, 
for  neither  of  these  words  means  excess  of  this  fluid.  Polyhydramnios 
exists  whenever  the  quantity  of  amnial  liquor  exceeds  two  and  one-half 
pints.  Baudelocque  stated  that  the  excess  might  reach  to  sixteen  litres, 
or  even  to  twenty-five,  about  thirty-three  to  fifty-two  pints. 

The  affection  occurs  oftener  in  the  multigravidse  than  in  primigra- 
vidse — according  to  McClintock,  23  to  5 ;  it  is  more  frequent  in  twin 
than  in  single  pregnancies,  and  in  the  former  case  the  children  are 
oftener  of  the  female  sex.  The  production  of  monstrosities  occurs 
more  frequently  in  polyhydramuios.  Syphilitic  disease  of  the  mother 
has  been  observed  in  many  cases  of  polyhydramnios.  In  some  cases — 
Depaul  has  reported  one — the  affection  occurred  in  an  ectopic  preg- 
nancy. In  twin  pregnancy  polyhydramnios  may  be  present  in  one 
ovum,  with  oligohydramuios  in  the  other. 

ETIOLOGY.  Polyhydramnios  has  been  attributed  to  various  causes. 
According  to  Jungbluth,  the  vasapropria,  which  usually  become  obliter- 
ated in  the  last  months  of  pregnancy,  remain  open,  and  hence  the  dis- 
ease. The  open  condition  of  these  capillaries  is  favored  by  obstruction 
to  the  foetal  circulation,  as  from  congenital  defects  of  the  heart  (Lebed- 
jew),  and  diseases  of  the  liver  (Kiistner).  Support3  is  given  the  hy- 
pothesis by  the  greater  frequency  of  malformations  and  death  of  the  foetus, 
and  a  large  and  oedematous  placenta  with  polyhydramnios.  It  has  been 
attributed  to  excessive  activity  of  the  renal  function.  It  has  also  been 
thought  to  result  from  disturbances  in  the  mother's  circulation,  as  shown 
by  great  oedema  or  by  dropsy.  In  some  cases  the  decidua  is  greatly 

1  ArchivdeTocologie,  1883.  3  Kormann.  »  Kleinwachter. 


458  THE  PATHOLOGY  OF  PREGNANCY. 

hypertrophied,  and  the  chorial  villi  are  swollen.  Gervis1  attributes  the 
affection  to  inflammation  of  the  amnion,  to  a  diseased  condition  of  the 
decidua,  and  to  dyscrasia  of  the  maternal  blood. 

In  two  of  several  cases  of  diabetes  mellitus  in  pregnancy,2  collected  by  Dr. 
Matthews  Duncan,  there  was  excess  of  amnial  liquor ;  one  of  the  two  occurred 
in  his  own  practice  and  the  other  in  that  of  Dr.  W.  L.  Reid,  of  Glasgow. 

FOEMS  OF  THE  DISEASE.  Polyhydramnios  occurs  in  two  forms, 
chronic  and  acute.  The  former  is  the  more  frequent,  and  does  not 
usually  appear  before  five  or  six  months  of  pregnancy.  It  is  char- 
acterized by  a  move  rapid  increase  in  the  size  of  the  abdomen  than  occurs 
in  normal  pregnancy,  the  foetal  movements  are  not  readily  felt  by  the 
mother,  nor  can  the  sounds  of  the  fcetal  heart  always  be  distinctly  heard 
by  the  obstetrician  ;  the  uterus  has  a  more  spheroidal  than  ovoidal  form, 
the  respiration  is  interfered  with,  and  the  patient  may  be  unable  to  lie 
down.  It  is  difficult  or  impossible  to  recognize  the  foetus  by  palpation, 
and  fluctuation  is  very  well  marked.  By  vaginal  examination  the  lower 
segment  of  the  uterus  is  found  drawn  up  into  the  abdominal  cavity, 
and  the  neck  of  the  uterus  is  more  or  less  effaced. 

The  acute  form,  which  may  suddenly  appear  in  a  case  in  which  the 
accumulation  has  hitherto  been  proceeding  gradually,  or  may  be  primi- 
tive, is  characterized  by  symptoms  similar  to  those  mentioned.  But 
the  discomfort  is  greater,  for  when  the  collection  is  gradual  the  system 
is  more  tolerant ;  but,  beside,  there  is  often  fever,  and  also  there  are 
nausea  and  vomiting  in  the  acute  form. 

It  is  more  frequently  observed  in  case  of  twins. 

Dr.  John  S.  Miller,  of  Philadelphia,  has  given  me  the  notes  of  a  case  of  poly- 
hydramnios  which  I  saw  in  consultation  with  him :  "  Mrs.  E  ,  thirty-five  years 
of  age,  had  previously  given  birth  to  six  healthy  children.  At  four  months  in 
her  seventh  pregnancy  was  larger  than  in  any  previous  pregnancy  at  term.  No 
fever,  but  persistent  vomiting  after  fourth  month.  Circumference  at  umbilicus, 
fifty-three  inches.  Miscarried  at  six  months  with  male  twins ;  one  large,  well 
developed,  and  lived  for  a  few  minutes  after  birth ;  the  other  small,  flattened, 
only  about  six  inches  long ;  the  excessive  quantity  of  fluid  came  from  the  sac 
occupied  by  the  larger  foetus.  The  quantity  actually  measured  was  thirty-one 
pints,  but  a  considerable  amount  escaped  in  the  bed." 

Bar3  maintains  that  as  great  pressure  affecting  the  portal  vein  causes 
ascites  in  the  adult,  so  increased  pressure  in  the  umbilical  vein  produces 
excess  of  amuial  liquor.  Mantel4  asserts,  from  a  very  thorough  study 
of  the  subject,  that  there  is  an  undeniable  frequent  coincidence  between 
the  insertion  of  the  placenta  at  the  lower  part  of  the  uterus  and  poly- 
hydramnios,  and  explains  the  latter  as  resulting  from  the  former  in 
consequence  of  the  pressure  which  the  placenta  thence  undergoes,  and 
the  modifications  of  circulation  in  the  cord ;  an  obstacle  to  the  normal 
course  of  the  blood  is  presented,  and  hence  blood-stasis  and  a  consider- 
able osmosis  into  the  amnial  cavity. 

Polyhydramnios  occurs  probably  once  in  150  labors.      The  acute 

1  St.  Thomas's  Hospital  Reports. 

2  Transactions  of  the  London  Obstetrical  Society,  vol.  xxiv. 

s  Journ.  de  M6d.  de  Paris,  January,  1889.  4  Arch,  de  Tocol.,  1888. 


DISEASES  OF  THE  OVUM.  459 

form  is  very  rare.  The  prognosis  for  the  foetus  is  unfavorable ;  in 
McClintock's  cases,  out  of  33  children  9  were  stillborn  and  10  died 
within  a  few  hours  after  birth ;  25  of  the  33  children  were  females. 

Spiegelberg  has  remarked  that  he  knew  "a  number  of  instances  in 
which  the  hydramuiotic  uterus  was  mistaken  for  a  simple  ovarian  cyst, 
and  tapped ;  this  has  happened  once  in  my  own  maternity.  Greater 
care  in  making  the  diagnosis  will  prevent  making  such  mistakes." 
Nevertheless,  Winckel  states  that  a  definite  diagnosis  in  some  cases  is 
impossible,  and  it  might  be  advisable  then  to  resort  to  exploratory 
abdominal  section.  This  was  done  by  Wilson,1  of  Baltimore. 

Errors  in  diagnosis  are  to  be  avoided,  first,  by  establishing  the  fact 
of  pregnancy  by  subjective  and  objective  signs ;  among  the  latter, 
Braxtou  Hicks's  will  in  some  cases  be  of  great  value ;  second,  by  recog- 
nizing the  enlargement  as  being  in  contact  with  the  abdominal  wall  in 
the  median  line;  third,  by  finding  the  lower  segment  of  the  uterus  very 
high,  and  more  or  less  complete  effacernent  of  the  cervix ;  fourth,  by 
carefully  studying  the  history  of  the  enlargement  as  to  position,  as  to 
progress,  and  as  to  symptoms  produced.  Runge  advises  in  doubtful 
cases  examination  during  anaesthesia. 

TREATMENT.  This  is  palliative  and  expectant,  unless  grave  symp- 
toms arise  from  the  excessive  distention  ;  when  these  occur  the  pregnancy 
should  be  ended.  It  has  been  advised  to  puncture  the  membranes  high 
up,  and  to  use  the  hand  as  a  tampon  to  check  the  rapid  discharge  of  the 
amnial  fluid.  Of  course,  if  a  transverse  presentation  occurs,  turning 
must  be  resorted  to,  otherwise  it  is  better  to  leave  the  labor  to  nature ; 
it  should  be  remembered  that  atony  of  the  uterus  may  result  from  its 
very  great  distention,  and  hence  there  is  a  liability  to  post-partum  hem- 
orrhage, which  should  be  carefully  guarded  against. 

In  some  cases  puncture  of  the  uterus  through,  the  abdomen  has  been  employed 
to  relieve  the  excessive  distention.  Even  if  premature  labor  or  abortion  re- 
sult, this  could  hardly  be  regarded  as  an  evil.  But  in  two  cases,  one  reported 
by  Tillaux  and  the  other  by  Lepage,  the  pregnancy  did  not  end  until  a  month 
after  the  operation.2  In  a  case  mentioned  by  Brouardel  the  condition  was  mis- 
taken for  an  ovarian  cyst,  puncture  followed  by  free  evacuation  of  the  amnial 
liquor  was  done,  and  the  pregnancy  continued  three  months.  Schatz  recom- 
mended puncturing  the  uterus  from  time  to  time  with  a  fine  trocar,  drawing  off 
a  portion  of  the  fluid,  so  that  premature  interruption  of  pregnancy  may  be  pre- 
vented. 

THE  PATHOLOGY  OF  THE  FCETUS.  The  pathology  of  foetal  life 
includes  malformations,  usually  arising  from  arrests  of  development, 
teratogeny,  or  the  formation  of  monstrosities,  constitutional  and  local 
diseases,  injuries,  and  death.  So  far  as  any  of  these  cause  difficulties 
in  delivery,  they  will  be  considered  in  connection  with  the  pathology  of 
labor. 

Vices  of  conformation  are,  as  previously  stated,  usually  arrests  of 
development.  Thus  there  may  be  harelip,  or  spina  bifida,  and  the 
origin  of  each  has  been  presented.  An  imperforate  anus  or  vagina  was 
normal  at  a  certain  period  of  evolution,  and  only  its  permanence 

1  American  Journal  of  Obstetrics,  1887. 

2  Revue  Medico-chirurgicale  des  Maladies  des  Femmes,  December,  1889. 


460  THE  PATHOLOGY  OF  PREGNANCY. 

renders  its  pathological  ;  so,  too,  in  regard  to  duplicity  of  the  vagina 
and  of  the  uterus.  In  some  instances  there  may  be  defective  for- 
mation of  one  or  more  members,  and  hence  one  kind  of  monstrosity 
known  as  ectromelic  ;l  in  the  gravest  form  the  monstrosity  is  without 
members  —  that  is,  an  amelic.2  Occasionally  there  may  be  excess  of  mem- 
bers, superfluous  development  ;  thus  there  may  be  six  fingers  on  each 
hand,  an  anomaly  so  common  among  the  Romans  that  they  gave  the 
name  of  Sexdigiti?  to  persons  having  six  fingers.  In  many  cases  the 
anomaly  has  been  found  hereditary. 

ACUTE  INFECTIOUS  DISEASES.  The  fact  that  the  foetus  may  suffer 
from  variola  has  been  established  in  numerous  instances.  So,  too,  there 
have  been  a  few  cases  reported  of  children  born  with  the  eruption  of 
rubeola.  Thomas  stated  in  1874  that  there  were  only  6  cases  of  certain 
transmission  of  the  disease  to  the  foetus  ;  but  3  have  been  reported 
since,  one  of  them  being  by  Lomer.4  In  more  frequent  cases  the  child 
has  been  attacked  with  measles  shortly  after  birth,  but  so  soon  that  the 
•intra-uterine  transmission  of  the  disease  cannot  be  questioned.  The 
proof  that  the  poison  of  scarlatina  may  affect  the  foetus  rests  upon  a 
few  cases.  It  cannot  be  doubted  that  the  child  while  in  the  uterus  may 
suffer  from  malarial  fever,  and  the  observations  of  Dr.  Bemiss,  pre- 
viously given,  render  it  probable  that  it  may  also  have  yellow  fever. 

Hirst5  quotes  an  instance  in  which  the  specific  bacilli  of  typhoid 
fever  were  found  in  the  foetus,  the  mother  having  had  the  disease.  A 
similar  fact  has  been  reported  by  Eberth.6  Vinay,  accepting  the  trans- 
mission of  the  typhoid  bacillus  to  the  foetus,  suggests  that  if  the  latter 
is  dead  at  birth  it  has  been  killed  by  the  typhoid  germ  or  by  the  toxiues 
it  secretes.  Recognizing  pneumonia  as  an  acute  infectious  malady,  it 
was  thought7  probable  that  pneumococci  might  pass  from  a  mother 
suffering  with  the  disease  to  her  foetus,  and  such  transmitted  affection 
was  in  some  cases  the  cause  of  foetal  death;  the  intra-uterine  trans- 
mission of  pneumonia  is  now  admitted.  Instances  showing  the  prob- 
able infection  of  the  foetus  with  erysipelas  from  the  mother  have  been 
published. 

CHRONIC  INFECTIOUS  DISEASES.  A  few  instances  of  congenital  tuber- 
culosis have  been  observed.  (See  page  422.) 

Foetal  syphilis  is  very  frequent.  The  changes  caused  in  the  foetus 
by  syphilis  "are  found  in  its  skin,  thymus,  lungs,  liver,  spleen,  supra- 
reuals,  pancreas  and  intestine,  on  its  serous  membranes  and  in  its  bones  ; 
they  are  most  constant  in  the  latter  and  in  the  spleen."  In  the  spleen 
no  pathological  products  have  been  found,  but  the  organ  is  greatly 
enlarged.  An  osteo-chondritis  is  the  special  manifestation  of  syphilis, 
and  is  found  in  the  tubular  bones,  the  lowest  end  of  the  femur  usually 
showing  the  most  striking  changes.  The  disease  "  begins  with  an 
excessive  proliferation  of  the  cells  at  the  margin  of  the  epiphysis,  which 
is  rapidly  followed  by  an  irregular  calcareous  infiltration  and  sclerosis 


i  From  "E/crpwCTif  ,  abortion,  and  [i£ho£,  a  member.  *  From  a  privative,  an 

3  Probably  the  first  historical  reference  to  a  person  having  supernumerary  fingers  and  toes  is  in 
the  Bible,  2  Samuel,  chap,  xxi.,  ver.  20.  - 

*  Centralblatt  f.  Gynakol.,  1889. 

*  American  System  of  Obstetrics,  vol.  i.  6  Arch,  de  Tocologie,  1889. 
f  De  la  Pneumonic  pendant  la  Grossesse,  Annales  de  GynScol.,  1889. 


DISEASES  OF  THE  OVUM.  461 

of  the  newly  formed  tissue."  If  the  child  is  born  living,  it  is  usually 
feeble,  under-sized,  its  skin  presenting  syphilitic  eruptions,  pemphigus 
and  impetigo,  and  there  are  buccal  and  genital  mucous  patches.  Its 
cry  is  weak,  and  it  suffers  from  obstinate  coryza. 

RHACHITIS.  Intra-uterine  rickets  produces  similar  deformities  to 
those  caused  by  the  disease  occurring  after  birth.  Fractures  of  bones 
are  not  uncommon,  and  the  limbs  are  not  developed  in  proportion  to 
the  trunk,  but  are  short. 

SPONTANEOUS  AMPUTATIONS.  These  may  concern  the  upper  or  the 
lower  limbs,  more  frequently,  however,  the  latter;  they  are  caused 
either  by  amniotic  bands  or  by  the  cord  encircling  the  member  that 
becomes  mutilated,  producing  a  constriction  which  prevents  the  part 
below  the  constricted  place  receiving  any  blood ;  if  the  bone  be  carti- 
laginous, there  is  no  improbability  in  the  statement  that  complete  section 

FIG.  183. 


SPONTANEOUS  INTKA-UTERINE  AMPUTATION. 

may  occur,  but  in  some  cases  at  least  of  spontaneous  amputation  the  final 
separation  of  the  member,  after  constriction  of  the  soft  parts,  has  resulted 
from  a  fracture.  Cases  of  amputation  cannot  be  confounded  with  those 
where  there  has  been  deficient  development,  for  the  amputated  member  has 
been  expelled  with  the  foetus  from  the  utecus.  Generally  those  foetuses 
to  whom  this  accident  has  happened  are  stillborn. 

SPONTANEOUS  AND  ACCIDENTAL  FRACTURES.  Chaussier  saw  one 
foetus  with  43  fractures  in  different  parts  of  the  skeleton,  and  another 
with  113.  The  late  Dr.  Hodgeu,  of  St.  Louis,  reported  the  case  of  a 
child  which  at  birth  had  65  fractures ;  he  attributed  them  to  muscular 
action  during  intra-uterine  life.1  Branfoot2  reports  delivering  a  foetus 
with  the  femurs  and  both  bongs  of  each  leg  fractured.  Fractures  may 
be  caused  by  external  violence  to  the  mother.  Packard3  gives  cases  in 
which  the  broken  bones  were  firmly  united  at  birth,  but  others  in  which 
there  was  no  union.  Brinton  has  reported  two  cases  of  intra-uterine 
fracture,  one  of  the  tibia,  the  other  of  the  clavicle,  occurring  from  in- 
iuries  received  by  the  mothers.4 

LUXATIONS.     Dislocations  of  bones,  more  especially  of  the  femurs, 

1  St.  Louis  Medical  and  Surgical  Journal,  1882. 

2  British  Medical  Journal,  1888. 

3  International  Encyclopaedia  of  Surgery,  vol.  iv. 

*  Transactions  of  the  American  Surgical  Association,  vol.  ii. 


46 2  THE  PA THOLOG  Y  OF  PREGNA NCY. 

occurring  in  the  foetus  are  not  absolutely  rare,  though  their  etiology  is 
obscure.  They  are  observed  more  frequently  in  females  than  in  males. 
In  some  instances  they  may  be  the  result  of  external  violence,  but  in 
most  no  such  cause  can  be  adduced ;  and,  therefore,  they  are  attributed 
to  "anomalous  development  of  articular  cavities." 

TUMORS.  In  addition  to  the  tumors  caused  by  spina  bifida,  ompha- 
locele, meningocele,  or  encephalocele,  various  other  tumors,  fluid  or 
solid,  may  be  found  upon  different  parts  of  the  body.  Some  of  these 
are  pedunculated  ;  others  attached  by  a  broad  base;  sometimes  they  are 
so  large  as  to  render  parturition  difficult  or  impossible  without  operative 
means. 

DEATH  OF  THE  FOZTUS.  The  foetus  having  perished  from  disease  or 
injury,  whether  affecting  it  directly  or  mediately,  we  have  next  to  study 
the  diagnosis  and  the  consequences  of  its  death. 

DIAGNOSIS  OF  THE  DEATH  OF  THE  FCETUS.  The  previous  recogni- 
tion of  the  foetus  being  alive  facilitates  the  inquiry  as  to  its  being  dead ; 
by  the  continued  absence  of  those  signs  which  gave  conclusive  proof  of 
its  life,  we  have  a  strong  probability  of  its  death ;  this  absence  must  be 
ascertained  by  a  most  careful  examination — indeed,  it  is  safer  to  repeat 
the  examination  once  or  oftener.  The  death  may  have  occurred  prior 
to  the  time  that  positive  proofs  of  life  were  available,  or  they  may  not 
have  been  ascertained.  We  inquire  as  to  whether  any  injurious  influ- 
ences, paternal,  maternal,  or  directly  acting  upon  the  foetus,  the  common 
result  of  which  is  death,  have  been  present.  Thus,  the  father  or  the 
mother  may  be  affected  with  syphilis,  the  mother  may  have  had  an 
acute  infectious  disease,  or  received  some  severe  injury.  The  absence 
of  foetal  movements,  which  the  mother  had  certainly  recognized;  the 
deterioration  of  her  health;  the  breasts,  after  having  been  full,  and 
possibly  secreting  milk,  becoming  flaccid ;'  she  is  pale  or  sallow,  has 
occasional  chilly  sensations,  the  abdominal  wall  somewhat  relaxed,  and 
she  may  complain  of  what  seems  a  dull  weight  in  the  abdomen,  falling 
from  one  to  the  other  side,  in  correspondence  with  changes  of  position 
in  bed.  The  temperature  of  the  uterus,  being  greater  than  that  of  the 
vagina  in  pregnancy,  will  noV  show  no  such  change;  but  this  examina- 
tion is  rarely  made.  There  is  one  sign  constantly  available  which, 
I  believe,  is  a  positive  proof  of  the  death  of  the  foetus,  and  that  is,  if, 
with  the  negative  evidence  furnished  by  auscultation  and  palpation, 
there  is  found  regular  diminution  in  the  size  of  the  abdomen,  the 
woman  not  suffering  from  any  disease  explaining  this  change,  we  are 
justified  in  concluding  that  the  child  is  dead. 

There  may  be  conjoined  with  examination  by  measurement  of  the 
abdominal  circumference,  weighing  the  patient  from  week  to  week ;  if 
the  child  be  dead  she  will  probably  lose  in  weight,  whereas  if  it  be  alive 
there  will  be  a  constant  gain. 

CONSEQUENCES  OF  THE  DEATH  OF  THE  FOZTUS  OK  EMBRYO.  These 
are  remote  or  immediate.  The  only  remote  consequence  is  the  expulsion 
of  the  uterine  contents,  and  this  will  be  first  considered — very  briefly, 
however,  because  the  subject  must  be  presented  elsewhere.  The  expul- 

1  One  of  the  aphorisms  of  Hippocrates  is  that,  if  the  mammae  of  a  pregnant  woman  suddenly 
begin  to  lessen  in  size,  she  will  abort. 


DISEASES  OF  THE  OVUM.  463 

sion  usually  takes  place  within  two  weeks,  and  if  delayed  beyond  that 
time  the  name  given  is  missed  abortion.  There  may  be  delay  for  a  few 
weeks,  or  even  for  several  months.  In  the  case  of  one  of  twins  dying 
during  pregnancy  it  is  not  unusual  for  it  to  be  retained  until  the  normal 
end  of  pregnancy,  and  then  it  is  expelled  along  with  the  living  child. 
Such  cases,  improperly  interpreted,  have  furnished  an  argument  for 
superfcetation.  So,  too,  in  a  single  pregnancy,  a  three-months'  fcetus, 
for  example,  may  be  expelled  at  the  end  of  nine  mouths'  gestation,  and 
this  ought  to  be  borne  in  mind  by  the  practitioner,  lest  a  wife,  her 
husband  having  been  absent  for  some  months  before  such  expulsion,  may 
suffer  unjust  suspicion  or  reproach. 

THE  IMMEDIATE  CONSEQUENCES  OF  DEATH  OF  THE  PRODUCT  OF 
CONCEPTION.  Certain  changes  follow  this  event ;  they  are  liquefaction, 
mummification,  maceration,  and  putrefaction. 

1.  Liquefaction.     This  may  occur  during  the  first  two  months  at 
least,  the  embryo  being  dissolved  so  completely  that  no  trace,  or  only  a 
trace,  of  it  is  left.    The  amnial  liquor  becomes  thick  and  opaque,  some- 
times having  a  milk-like  appearance  like  an  emulsion.     Important 
changes  meanwhile  occur  in  the  fcetal  appendages.     If  myxomatous 
degeneration  of  the  chorial  villi  has  already  begun,  it  continues.     But 
more  frequently  the  formation  of  what  has  been  termed  a  fleshy  mole1 
follows.     This  is  composed  of  the  deciduous  membranes,  and  the  mem- 
branes of  the  ovum,  with  a  central  cavity  occupied  as  mentioned,  of 
the  placenta  in  process  of  formation,  and  of  blood  which  is  infiltrated 
between  the  chorial  villi  and  between  the  membranes.     The  separation 
between  the  mass  and  the  uterus  being  incomplete,  the  former  is  nour- 
ished, and  growth  of  its  elements  continues,  the  clots  are  absorbed,  or 
the  fibrin,  according  to  Scanzoni,  becomes  organized,  the  amnial  cavity 
grows  smaller,  and  finally  a  nearly  solid  mass  results.     The  "  fleshy 
mole  "  may  be  retained  in  the  uterus  for  some  weeks,  giving  rise  mean- 
time to  occasional  attacks  of  uterine  "  pains"  and  hemorrhage. 

In  1892  I  published2  a  brief  study  of  fifty-four  cases  of  molar  pregnancy. 
Only  four  occurred  in  primigravidse,  and  the  mean  duration  of  the  pregnancy 
was  three  to  four  months.  In  that  paper  I  attributed  chief  importance  to  disease 
of  the  chorial  villi,  as  indicated  by  microscopic  examination.  But  the  fact  of 
almost  all  the  cases  occurring  in  multigravidse  leads  me  now  to  the  conclusion 
that  usually  the  primary  factor  is  disease  of  the  deciduse. 

2.  Mummification.     This  has  been  compared  to  the  change   which 
a  fruit  undergoes  when  kept  in  alcohol.     The  soft  tissues  of  the  foatus 
become  condensed,  contracted,  Hardened,  dried  up,  and  thus  it  is  less- 

1  Depaul  has  remarked  that  (Dictionnaire  Encyclop&dique  des  Sciences  Mfidicales,  second  series, 
vol.  ix.)  "  nothing  is  yet  more  obscure  to-day  than  the  etymology  of  the  word  mole.    The  most 
natural  is  that  which  derives  it  from  the  Latin  word  moles,  which  signifies  mass."    I  think  that 
Depaul  was  mistaken.    It  seems  that  both  Hippocrates  and  Aristotle  applied  the  word  Mi/b? 
which  originally  meant  a  mill,  to  "  a  hard  formation  in  a  woman's  womb."    From  this  word  the 
Romans  had  mola,  also  primarily  meaning  a  mill ;  Pliny  certainly  applied  mola  to  such  an  intra- 
uterine  formation  as  has  been  mentioned.    But  both  fii^h]  and  mola  mean  secondarily  the  stone 
which  was  essential  for  grinding.    Hippocrates  undoubtedly  had  observed  calcified  fibroids  dis- 
charged from  the  uterus,  and  it  was  quite  natural  that  such  a  formation  should  be  called  fivty, 
The  application  of  the  term  to  other  solid  masses  expelled  from  the  uterus  would  obviously 
follow.    And,  therefore,  the  derivation  of  the  terra  mole  from  moles  is  unnecessary,  for  it  seems 
properly  to  originate  from  the  Greek  pmkr]^  the  Latin  mola. 

2  American  Journal  of  the  Medical  Sciences,  October. 


464          THE  PATHOLOGY  OF  PREGNANCY. 

ened  in  size  and  presents  a  shrivelled  appearance  ;  its  color  becomes  a 
dull  gray  or  yellow.  The  amnial  liquor  finally  disappears,  leaving  as  a 
residue  an  earthy,  grayish  sediment  "  similar  to  the  deposit  left  by  a 
stream  after  an  overflow  of  its  banks."  Mummification,  of  course, 
does  not  occur  if  the  membranes  have  been  ruptured,  nor  is  it  usually 
seen  except  in  a  foetus  of  three  to  four  months. 

3.  Maceration.  The  macerated  foetus  is  larger  than  corresponds 
with  the  period  of  intra-uterine  life  at  which  it  perished  ;  it  is  swollen, 
its  form  changed,  the  abdominal  cavity  is  often  greatly  distended ;  its 
tissues  are  softened,  the  bones  lose  their  firm  attachment,  and  especially 
those  of  the  cranium  move  freely  upon  pressure ;  the  skin  presents 
numerous  blebs,  and  the  epidermis  comes  off  in  large  flakes,  showing 
the  derm  beneath  of  a  dusky  red ;  the  serous  cavities  contain  blood- 
stained serum,  and  the  blood  escaped  from  its  vessels  contributes  its 
coloring-matter  to  dyeing  the  tissues;  it  is  sometimes  known  as,  foetus 
sanguinolentus.  Runge  states  that  in  70  to  80  per  cent,  of  cases  the 
macerated  foetus  presents  evidences  of  syphilis. 

Ribemont-Dessaignes,1  after  referring  to  the  generally  admitted  view  that  the 
external  signs  of  maceration— the  formation  of  blebs  and  the  detachment  of  the 
epidermis— are  not  manifested  until  the  third  day  after  the  death  of  the  foetus, 
holds  that  these  lesions  may  appear  much  earlier,  a  few  hours  after  death,  and 
even  upon  the  living  foetus,  and  adduces  cases  in  illustration. 

4  Putrefaction.  This  occurs  when  the  membranes  have  been  rup- 
tured, and  thus  air  gets  access ;  air  with  moisture  and  warmth  furnishes 
the  essential  conditions  for  putrefactive  changes.  Putrefaction  occurs 
very  rapidly,  and  McClintock2  stated  that  he  had  seen  the  uterus  be- 
come quite  tympanitic  from  this  cause  after  the  accession  of  labor  and 
before  delivery.  The  abdomen  of  the  foetus  is  distended  by  gas,  the 
connective  tissue  emphysematous,  crepitating  upon  pressure,  the  entire 
body  and  members  greatly  swelled,  so  that  serious  difficulty  in  delivery 
may  be  presented,  and  a  horrible  odor  exhales  from  the  foetus.  In 
some  cases  gas  accumulates  in  the  uterus,  a  condition  known  as  physo- 
metra,  and  the  organ  is  greatly  distended  and  tympanitic.  Generally 
the  eifect  of  foetal  putrefaction  upon  the  mother  is  more  or  less  grave ; 
she  has  chills,  fever,  diarrhoea,  and  death  may  result  from  the  infection 
of  her  system,  unless  the  decomposing  foetus  be  promptly  removed,  and 
appropriate  local  antisepsis  be  employed. 

ABORTION.  Abortion  is  the  expulsion  of  the  product  of  conception 
before  the  foetus  is  viable.  Miscarriage  is  commonly  used  as  a  synonym, 
though  by  some  it  is  restricted  to  an  abortion  occurring  after  three 
months  ;3  the  reason  for  this  distinction  is  that  the  treatment  of  the  acci- 
dent varies  at  these  different  periods.  But  such  distinction  is  purely 
arbitrary.  Further,  abortion  has  been  divided  into  ovular,  embryonic, 
and  foetal ;  the  first  is  applied  to  an  abortion  in  the  first  three  weeks, 
the  second  to  that  which  happens  between  the  end  of  the  three  weeks 
and  of  the  first  three  months,  and  foetal  is  used  to  designate  the  acci- 
dent from  the  end  of  three  to  that  of  six  months. 

1  Annales  de  Gynecologic,  July,  1889. 

2  Note  to  Sydenham's  Society's  edition  of  Smellie's  Midwifery. 

3  Miscarriage  in  this  restricted  sense  is  also  called  partus  immaturw. 


DISEASES  OF  THE  OVUM.  465 

CLASSIFICATION.  Abortion  has  been  divided  into  spontaneous,  or 
natural,  and  accidental ;  by  the  former  a  miscarriage  occurring  from 
obscure  or  latent  causes  is  designated,  and  by  the  latter  one  that  has  an 
obvious  cause.  But  this  distinction  is  in  many  cases  impossible  to  be 
made.  A  better  division  is  into  spontaneous  and  artificial.  The  latter 
class  is  divided  into  therapeutic  and  criminal ;  therapeutic  abortion  is 
that  which  is  done  by  the  physician  in  the  interest  of  the  mother's  life 
or  health,  while  criminal  abortion  is  without  this  or  any  other  justifica- 
tion. The  term  incomplete,  or  imperfect,  is  applied  to  abortions  in 
which  the  entire  ovum  is  not  expelled.  Missed  abortion  has  been  pre- 
viously defined. 

FREQUENCY.  There  are,  and  there  can  be,  no  data  by  which  the 
absolute  or  relative  frequency  of  abortion  can  be  ascertained,  for  many 
cases  occur  without  the  subjects  knowing  it,  and  many  other  abortions 
are  self-produced,  or  performed  by  professional  abortionists,  and,  there- 
fore, kept  secret ;  in  only  exceptional  instances  when  a  fatal  result  fol- 
lows do  medical  men  or  the  public  know  of  them.  Whitehead's  statis- 
tics1 show  that  87  per  cent,  of  women  living  in  wedlock  until  after  the 
menopause  had  aborted  at  some  time  in  their  married  life.  Priestley2 
estimates  the  number  of  abortions  as  one  to  four  labors ;  Ahlfeld,  one 
in  five.  But  even  the  former  proportion,  though  greater  than  given  by 
most  Avriters,  is  probably  too  small.  The  sterility  of  prostitutes  as  well 
as  that  of  many  newly  married  women  may  frequently  be  attributed  to 
early  abortion. 

TIME  OF  ABOETION.  The  greater  number  of  miscarriages  occur  in 
the  first  three  months  of  pregnancy.  There  is  an  exception  to  this  rule, 
however,  given  by  those  cases  of  criminal  abortion  which  become  sub- 
jects of  judicial  inquiry.  Tardieu3  has  shown  by  statistics  collected  by 
himself  and  others  that  criminal  abortion  is  more  frequent  from  the 
third  to  the  sixth  month  than  in  the  first  two  months.  The  explana- 
tion of  this  fact  is,  that  up  to  three  months  a  woman  hopes  there  is 
simply  a  delay  in  the  appearance  of  the  flow,  but  when  this  hope  fails 
she  is  ready  to  resort  to  active  means  to  end  a  pregnancy  which  has 
now  become  almost  certain ;  on  the  other  hand,  when  six  months  have 
elapsed  the  life  of  the  child  has  become  so  manifest  that  she  shrinks 
from  its  destruction — foatal  movements  make  successful  appeal  to  the 
mother's  conscience,  if  not  to  her  love  also,  for  the  salvation  of  the  new 
life  which  dwells  within  her  womb  as  its  sanctuary.  The  great  majority 
of  spontaneous  abortions  occur  at  a  time  corresponding  with  a  monthly 
flow ;  Boerhaave  made  the  proportion  nine  out  of  ten. 

CAUSES  OF  ABORTION.  Very  trifling  causes  may  produce  miscar- 
riage in  some  women.  La  Motte  has  said  that  a  misstep,  raising  the 
arms  too  high,  a  strong  odor,  as  of  musk,  amber,  or  civet;  a  bad  odor, 
as  from  a  dead  animal  in  the  road,  from  a  charcoal  fire  just  kindled,  or 
from  a  lamp  or  candle  imperfectly  extinguished,  may  end  the  pregnancy 
in  some.  On  the  other  hand,  the  most  active  exercise,  the  severest 
injuries,  grave  surgical  operations,  the  most  cruel  violence,  or  the  use 
of  enormous  doses  of  irritant  medicines  reputed  abortive,  have  not 
caused  miscarriage  in  others. 

1  Abortion  and  Sterility.  2  Op.  cit.  3  Etude  Medico-legalesurl'Avortement. 

30 


466  THE  PATHOLOGY  OF  PREGNANCY. 

Instances  of  frequently  recurring  abortion  are  not  uncommon  ;  one 
has  been  mentioned  of  a  woman  who  miscarried  twenty-four  times  at 
three  months.  These  have  been  termed  habitual  abortion.  But,  as  re- 
marked by  Kleinwiichter,  habit  is  not  to  be  regarded  as  a  cause;  it 
would  be  more  rational,  since  habit  did  not  begin  the  series,  to  attribute 
the  abortion,  in  most  cases,  to  the  still  acting  original  cause.  Dr.  Meigs 
ascribed  so-called  habitual  abortions  to  excessive  irritability  of  the 
uterus ;  others  have  held  that  they  were  caused  by  a  want  of  nutritive 
material  in  the  uterus  for  its  complete  development,  the  organ  growing 
for  a  time,  and  then  the  growth  ceases  and  abortion  follows.  Neither 
hypothesis  rests  upon  established  facts,  but  each  indicates  the  incorrect- 
ness of  the  view  that  habit  is  its  cause. 

The  causes  of  miscarriage  do  not,  in  all  cases,  act  separately,  but  very 
frequently  two  or  more  are  combined.  Some  simply  predispose  to  the 
accident,  while  others  are  the  efficient  agents.  In  their  further  consid- 
eration, it  is  convenient  to  divide  them  into  paternal,  maternal,  and 
those  belonging  to  the  ovum. 

PATERNAL  CAUSES.  According  to  Deviliers,  the  procreative  power 
being  distinct  from  that  of  development,  the  evolution  of  the  product 
of  conception  is  almost  entirely  under  the  influence  of  the  degree  of 
vitality  of  the  mother.  Nevertheless,  the  father  being  syphilitic,  the 
foetus  may  be  infected  and  perish,  though  the  mother  remains  healthy. 
It  is  quite  possible,  too,  that  in  addition  to  syphilis  other  diseased  con- 
ditions of  the  father,  such  as  alcoholism  and  phthisis,  may  result  in  a 
fcetal  malady  which  is  incompatible  with  the  continuance  of  pregnancy. 
The  injurious  influence  of  lead-poisoning  acting  through  the  mother 
upon  the  foetus  has  been  shown  by  Constautin  Paul,1  Roque,2  and  Ren- 
nert.3  But  Lefour4  has  also  taught  that  if  the  father  be  a  worker  in 
lead,  the  mother  not  being  exposed  to  lead-poisoning,  there  is  great 
liability  to  abortion. 

MATERNAL  CAUSES.  These  may  be  divided  into  external  and  in- 
ternal, or  those  coming  from  without  and  those  acting  from  within. 
Among  external  causes  are  violent  exercise,  as  running,  dancing,  jump- 
ing, riding  on  a  hard  trotting  horse  or  over  a  rough  road;  lifting  heavy 
weights,  falls,  blows5  upon  the  abdomen,  compression  of  the  body  by 
clothing  or  by  corsets,  compression  of  a  varicose  limb,  the  use  of  the 
uterine  sound,  applications  to  the  cervix,  leeching  the  cervix  or  the  vulva, 
and  surgical  operations,  especially  if  involving  the  genital  zone.  Fre- 
quency of  coition  is  not  unseldom  a  cause  of  miscarriage.  Whitehead6 
has  stated  that  there  can  be  little  doubt  that  a  great  number  of  cases  of 
uterine  disease,  attended  with  vaginal  discharge,  and  frequently  result- 
ing in  abortion,  may  be  attributed  to  intemperate  sexual  intercourse 

1  Arch.  Gen.  de  Medecine,  1860.  -  Paris  Thesis,  1873. 

3  Arch,  fiir  Gynakol.,  1881.  «  Gaz.  hebd.  des  Sqi.  Med.  de  Bordeaux,  1887. 

6  History  gives  us  two  noted  instances  of  husbands  causing  abortion  by  kicking  their  wives. 
One  of  these  was  Cambyses,  the  son  of  Cyrus:  he  is  referred  to  in  "Ezra"  as  Ahasuerus.  He 
subjugated  Egypt  more  than  500  years  before  the  Christian  era ;  while  living  in  that  country, 
according  to  Herodotus,  he  married  his  sister,  and  one  day,  becoming  enraged  at  her  just  rebuke 
of  some  of  his  many  evil  acts,  kicked  her,  she  being  pregnant  at  the  time,  and  death,  preceded  by 
miscarriage,  resulted. 

In  Fleury's  Histoire  Ecclesiastique,  Paris,  1722,  it  is  stated  that  one  of  the  crimes  of  Novatus,  an 
heresiarch  of  the  Carthage  Church,  about  the  year  258  A.D.,  was  kicking  his  pregnant  wife,  causing 
miscarriage. 

0  Op.  cit. 


DISEASES  OF  THE  OVUM.  467 

during  pregnancy.  Depaul  held  that  two-thirds  of  spontaneous  abor- 
tions were  caused  by  coition,  while  Miquel,  of  Tours,  makes  the  pro- 
portion still  greater — nine  out  of  ten. 

Great  altitudes  are  said  to  be  a  cause,  and  it  is  asserted  that  in  certain 
mountainous  countries  pregnant  women  descend  to  the  valleys  to  escape 
the  accident.  Hot  climates  are  thought  by  some  to  cause  it.  This  effect 
has  also  been  attributed  to  hot  baths.  The  opinion  is  confirmed  by  the 
statement  of  Kormann1  that  when  used  to  excess  they  are  apt  to  pro- 
duce a  miscarriage. 

Among  internal  causes  are  acute  infectious  diseases.  Chronic  infec- 
tious diseases  differ  in  their  influence  upon  pregnancy,  phthisis  compara- 
tively seldom  arresting  it,  while  syphilis  frequently  does.  Olshausen 
regards  syphilis  and  retroflexiou  of  the  uterus  as  the  most  frequent 
causes  of  spontaneous  abortion.  Cardiac  disease  may  cause  abortion. 
Lydeu2  states  that  cardiopathics  frequently  miscarry,  and  this  is  the 
means  taken  by  nature  to  avoid  accidents.  Some  of  the  sporadic  dis- 
eases produce  the  same  result,  as  has  been  previously  mentioned;  so 
may  lead-poisoning  and  albuminous  nephritis.  It  is  by  some  held  that 
a  pregnant  woman  working  in  a  tobacco  factory  is  thereby  rendered 
liable  to  miscarriage.3  Abortion  may  result  from  violent  sneezing, 
coughing,  or  vomiting;  likewise  from  diarrhoea  or  dysentery.  Adhe- 
sions of  the  uterus  from  former  peritoneal  inflammation  may  prevent 
the  development  of  the  organ,  and  thus  end  the  pregnancy;  so,  too, 
rigidity  of  its  body,  or  relaxation  of  the  cervix,  are  regarded  as  causes. 
Abdominal  tumors  external  to  the  uterus  may  occupy  so  much  space 
that  there  is  no  room  for  the  pregnant  uterus,  and  hence  its  contractions 
resulting  in  expulsion  of  the  ovum  may  be  evoked.  Positional  and 
structural  diseases  of  the  uterus  are  causes.  Among  the  former  pro- 
lapse and  posterior  displacements  are  of  especial  significance;  among 
the  latter  malignant  diseases,  particularly  of  the  fundus,  polypi  and 
fibroid  tumors;  a  lacerated  cervix  may  cause  repeated  abortion.  Strong 
mental  emotions,  as  fear,  sorrow,  joy,  or  anger,  are  occasionally  causes. 
Whitehead  and  Duncan,  among  others,  have  mentioned  the  fact  that 
the  last  pregnancy  in  the  childbearing  period  is  quite  liable  to  end  in  a 
miscarriage. 

ABORTION  FROM  THE  USE  OF  MEDICINES.  It  sometimes  happens 
that  abortion  is  caused  by  the  use  of  drugs,  as,  for  example,  active 
cathartics,  or  even  laxatives  or  emetics.  It  may  be  that  in  some  cases 
the  administration  of  quinine  has  been  followed  by  miscarriage,  and 
while  in  almost  all  instances  the  .event  is  justly  attributed  to  the  disease 
for  which  the  medicine  is  given,  yet  possibly  the  latter,  in  a  few,  was, 
from  some  peculiarity  of  constitution  of  the  individual,  the  efficient 
agent.  Nevertheless,  neither  this  nor  any  other  drug  can  be  regarded 
as  an  abortifacieut ;  there  must  be  some  tendency  to  miscarriage,  some 
abnormal  condition  which  renders  those  who  thus  suffer  after  taking 
any  of  these  agents  liable  to  miscarry.  1  have  known  two  pregnant 
married  women  take  an  infusion  of  May-apple  in  such  large  quantity 

1  Op.  cit.  2  Berlin,  klin.  Wochenschrift,  1893. 

3  The  testimony  of  medical  men  who  have  investigated  this  subject  differs,  but  I  think  the 
weight  of  authority  is  in  favor  of  the  statement  made  in  the  text.  See  article  by  Dr.  Pradel,  Journ. 
de  Med.  de  Paris,  August  5, 1888. 


468  THE  PATHOLOGY  OF  PREGNANCY. 

as  to  produce  violent  catharsis  and  eraesis  with  great  prostration,  yet  in 
neither  was  the  pregnancy  interrupted. 

CAUSES  BELONGING  TO  THE  OVUM.  Velpeau,  after  examining  the 
ova  from  two  hundred  abortions  occurring  under  three  months,  found 
one-half  were  diseased.  The  various  diseases  of  the  decidua  that  have 
been  mentioned,  and  its  premature  atrophy,  are  frequent  causes ;  also 
placental  apoplexy  and  the  different  degenerations  of  the  placenta. 
Polyhydramnios  in  most  instances  causes  the  pregnancy  to  be  arrested, 
in  consequence  of  the  great  disteution  of  the  womb.  The  uterus,  too, 
in  many  cases  reacts  prematurely  in  consequence  of  similar  excessive 
distention  in  plural  pregnancy.  Abnormal  site  of  the  placenta  may 
cause  miscarriage.  The  foetus  may  be  affected  by  the  same  disease  as 
the  mother,  or  suffer  independently  of  her,  and  its  death  result  in  abor- 
tion. Disease  of  the  umbilical  cord,  or  its  compression,  may  have  a 
like  fatal  effect  upon  it,  and  thus  upon  the  pregnancy. 

SYMPTOMS.  In  some  cases  of  abortion  premonitory  symptoms  may 
be  observed.  These  are  alternate  flushes  of  heat  and  chilliness,  a  feel- 
ing of  languor  or  feebleness,  lumbar  pain,  a  sensation  of  pelvic  weight, 
of  fulness  of  the  lower  part  of  the  abdomen,  some  irritability  of  the 
bladder,  and  possibly  of  the  rectum  also. 

The  characteristic  symptoms  are  hemorrhage  and  painful  contractions ; 
contractions  are,  indeed,  the  efficient  cause  of  abortion.  In  the  first 
weeks  abortion  may  be  readily  mistaken  by  the  woman  herself,  especially 
if  she  has  had  other  early  miscarriages,  and  by  the  physician  for  an  attack 
of  dysmenorrhcea.  But  the  rule  is,  that  in  the  latter  pain  precedes  the 
flow  of  blood,  whereas,  in  the  former,  the  phenomena  occur  in  the  re- 
verse order,  or  else  they  are  simultaneous.  Some  cases  have  early  in  their 
progress  a  gush  of  watery  fluid  slightly  discolored  with  blood ;  this 
discharge  does  not  necessarily  indicate  rupture  of  the  ovum,  and  hence 
that  miscarriage  is  inevitable,  for  it  may  occur  from  catarrhal  endome- 
tritis.  But  no  such  discharge  occurs  either  before  or  during  menstrua- 
tion. Usually  the  flow  of  blood  is  very  much  greater  than  that  which 
occurs  in  menstruation.  Further,  it  is  possible  some  of  the  reflex 
disturbances  arising  from  pregnancy  may  have  appeared ;  and  if  so, 
this  fact  will  assist  in  making  a  diagnosis.  The  final  proof  of  the  case 
being  one  of  abortion  and  not  of  difficult  menstruation  would  be  find- 
ing the  ovum  in  the  discharge,  possibly  surrounded  by  a  clot  of  blood. 
The  ovum  of  an  early  abortion  is  generally  entire,  though  the  fact  that 
the  sac  is  ruptured  is  not  a  proof,  as  claimed  by  some,  that  the  miscar- 
riage has  resulted  from  criminal  means.  In  some  cases  occurring  from 
the  first  to  the  second  month,  blood  may  not  only  be  effused  between 
the  decidua  and  the  chorion,  but  also  penetrate  the  chorion  and  then  the 
amnion,  more  or  less  completely  filling  the  amuial  cavity. 

If  the  pregnancy  has  advanced  to  seven  or  eight  weeks,  or  further, 
but  still  not  reached  three  months,  the  symptoms  of  abortion  are  usually 
quite  plain.  The  suffering,  the  regular  recurrence  of  the  pains,  and  the 
marked  hemorrhage,  scarcely  leave  room  for  doubt.  It  is  a  labor  in 
miniature,  at  least  so  far  as  it  relates  to  the  expelling  organ  and  to  the 
expelled  product,  but  not  in  miniature  in  regard  to  the  duration  of  the 
process  and  the  attendant  suffering.  The  ovum  is  in  the  majority  of 


DISEASES  OF  THE  OVUM.  469 

cases  expelled  entire  if  there  has  been  no  improper  interference.  The 
chorial  villi  are  very  distinct,  and,  as  Pajot  has  said,  the  entire  external 
surface  of  the  ovum  is  placenta.  The  deciduous  membranes  are  usually 
discharged  afterward — at  least  a  considerable  portion  of  these  does  not 
pass  off  with  the  ovum. 

If  the  pregnancy  has  advanced  to  three  months  or  beyond — that  is,  if 
the  abortion  be  foetal — the  ovum  is  usually  ruptured  in  the  process,  and 
the  foetus  is  expelled  first  and  its  appendages  afterward  ;  in  this  respect 
the  course  is  similar  to  that  of  labor.  A  delay  of  many  hours,  or  even 
of  several  days,  may  occur  in  the  expulsion  of  the  foetal  appendages ; 
and  during  this  retention  the  patient  is  liable  to  attacks  of  hemorrhage, 
or  she  may  have  a  bloody  and  purulent  offensive  discharge. 

It  happens  in  some  cases  that  after  severe  pains,  and  more  or  less  hemorrhage 
with  dilatation,  so  that  the  finger  can  touch  the  ovum,  even,  too,  with  discharge 
of  a  fragment  of  decidua,  as  has  been  observed  by  Spiegelberg,  Matthews  Dun- 
can, and  others,  the  symptoms  of  miscarriage  gradually  cease,  and  the  preg- 
nancy is  completed.  More  frequently,  however,  the  cessation  is  temporary ;  it 
may  last  some  hours,  or  even  days,  and  then  uterine  action  is  renewed,  and  the 
usual  result  follows.  In  those  cases  of  threatened  abortion  in  the  early  months 
in  which  the  symptoms  permanently  cease,  though  there  has  been  considerable 
hemorrhage,  the  discharge  came  from  detachment  of  the  ovum  at  its  lower  seg- 
ment ;  such  cases  are  usually  seen  before  the  placenta  is  completely  formed. 

In  the  fourth  month,  and  on  to  the  seventh,  the  course  of  abortion  is 
similar  to  that  of  premature  or  of  mature  labor,  the  process  being, 
however,  longer  than  in  labor,  because  the  cervical  changes  which  pre- 
cede the  latter  must  be  effected,  and  because  the  uterine  muscular  struc- 
ture is  imperfectly  developed.  Hemorrhage  is  less  to  be  feared  as  the 
seventh  mouth  is  approached ;  the  uterine  decidua  is  more  readily  cast 
off  in  late  than  in  early  abortions.  Before  the  formation  of  the  pla- 
centa the  hemorrhage  comes  from  the  entire  internal  surface  of  the 
uterus,  but  after  this  has  taken  place  only  from  the  site  of  placental 
attachment.  Very  little  discharge  follows  an  abortion  in  the  early 
months  if  it  be  complete ;  but  if  a  portion  of  the  ovum  be  retained,  the 
hemorrhage  may  be  great.  Milk  is  usually  secreted  after  miscarriage, 
in  some  instances  even  when  that  occurs  quite  early  in  pregnancy. 

Prognosis.  If  the  abortion  be  inevitable,  of  course  the  foetus  dies, 
or  is  already  dead,  and  the  practitioner  is  concerned  with  the  interests 
of  the  mother  alone.  The  chief  immediate  dangers  are  hemorrhage  or 
septicaemia,1  which  may  be  general,  or  be  limited  to  a  local  pelvic  in- 
flammation. Tetanus  has  occasionally  followed.  Putrid  decomposi- 
tion of  fragments  left  in  the  uterus,  according  to  Kleinwachter,  is  less 
common  than  generally  believed,  because  of  the  difficult  entrance  of  air, 
and  because  manual  intervention  is  less  frequently  resorted  to  than  in 
birth  at  the  normal  time. 

The  fatality  following  criminal  abortion  is  very  great.  Hippocrates 
said  that  abortion  was  much  more  dangerous  than  labor,  because  the 
product  of  conception  could  not  be  destroyed  except  by  violent  means ; 
but  this  remark  is  especially  applicable  to  criminal  abortions. 

1  In  a  paper  upon  Midwifery  Among  the  Burmese,  the  author,  Dr.  Pedley,  states  that  "  puer- 
peral fever  is  recognized  by  Burmese  midwives,  and  seems  to  be  more  frequent  after  abortion." 
Transactions  of  the  London  Obstetrical  Society,  vol.  xxix. 


470  THE  PATHOLOGY  OF  PREGNANCY. 

Tardieu  states  that  in  116  of  this  class,  in  which  the  termination  was  certainly 
known,  death  occurred  more  or  less  promptly  in  60.  He  refers  to  cases  of  sud- 
den death  which  may  be  caused  by  embolism,  by  syncope,  either  from  excessive 
pain  or  from  the  moral  shock  created  by  the  consciousness  of  crime.  Other 
causes  which  conduce  to  the  fatality  of  criminal  abortion  are  the  secrecy  with 
which  the  operation  is  done;  usually  the  unhappy  victim  goes  to  the  house 
of  the  abortionist,^ and  he  or  she,  for  women  are  also  engaged  in  the  wicked 
work,  endeavors  to  puncture  or  detach  the  membranes,  possibly  wounding  the 
uterus  in  these  efforts,  in  many  instances  "  made  by  an  ignorant  or  brutal  hand, 
or  one  that  trembles  with  conscious  guilt."  After  the  operation  the  subject 
walks  or  rides  probably  a  long  distance  to  her  home,  and  there,  in  order  to  conceal 
all  knowledge  of  her  condition,  engages  in  her  usual  avocation  or  work,  until  grave 
symptoms  compel  her  to  rest,  and  possibly  to  send  for  a  physician. 

The  remote  dangers  of  abortion  are  chronic  parenchymatous  metritis, 
very  often  spoken  of  as  subinvolution,  and  positional  disorder  of  the 
uterus ;  a  portion  of  the  placenta  may  remain  and  be  converted  into  a 
placental  polypus,  or  hypertrophy  of  undetached  decidua  may  occur, 
and  either  be  the  cause  of  uterine  hemorrhage.  These  dangers  may  be 
prevented  in  most  cases  by  proper  care  during  and  after  abortion.  Unfor- 
tunately too  many  women  look  upon  miscarriage  as  a  trivial  matter, 
and  do  not  take  the  rest  after  it  that  they  ought. 

Treatment.  The  treatment  may  be  considered  under  three  heads, 
prophylaxis,  that  required  in  threatened  or  commencing  abortion,  and 
that  of  inevitable  abortion. 

Prophylactic  Treatment.  This  includes  a  recognition  of  the  causes 
of  miscarriage  in  individual  cases,  and  their  removal.  It  is  not  neces- 
sary to  repeat  the  etiology  of  this  accident,  nor  the  treatment  required 
in  different  cases.  In  habitually  recurring  abortion  the  probability  is 
that  syphilis,  or  uterine  retroflexion,  or  an  endometritis  is  the  cause. 

The  late  Professor  Henry  Miller,  of  the  University  of  Louisville,  who  was  one 
of  the  first  American  physicians  to  teach  and  to  practise  the  local  treatment  of 
uterine  diseases,  regarded  inflammation  of  the  lining  membrane  of  the  uterus 
as  one  of  the  most  frequent  causes  of  miscarriage,  and  urged  the  importance  of 
properly  treating  the  former  in  order  to  prevent  the  latter. 

When  a  woman  who  has  previously  aborted  becomes  pregnant  she 
should  be  advised  to  avoid  all  exercise  at  the  time  in  the  new  pregnancy 
corresponding  with  that  in  the  former  when  abortion  occurred.  So,  too, 
rest  at  the  times  corresponding  with  "  monthly  periods  "  should  be  en- 
joined. Sexual  intercourse  ought  to  be  forbidden. 

The  late  Sir  James  Y.  Simpson  advised  the  potassic  chlorate,  ten  to  twenty 
grains  three  times  a  day,  as  a  preventive  ;  he  gave  it  for  placental  disease  and 
also  as  a  means  of  arterializing  the  blood ;  it  is  impossible  for  it  to  produce  the 
effect  upon  the  blood  suggested.  Priestley  states  that  many  practitioners  have 
testified  to  its  utility  as  well  as  to  its  harmlessness,  and  suggests  that  it  may  act 
successfully  as  an  alkaline  salt  in  preventing  the  formation  of  congestive  and 
fibrinous  deposits  in  the  placenta.  A  preparation  from  the  bark  of  the  black 
haw  ( Viburnum  prunifolium)  was  recommended  by  Phares,  in  1866,  as  useful  in 
preventing  miscarriage ;  since  then  it  has  been  occasionally  indorsed  for  this 
purpose  by  others ;  Wilson  and  Campbell1  have  recommended  it  very  highly, 
sustaining  the  claims  previously  made  for  this  medicine,  that  it  is  a  tonic  and 
uterine  sedative  ;  pills  of  two  to  four  grains  of  the  solid  extract  were  given  three 
or  four  times  a  day  ;  Wood2  states  that  we  have  no  exact  knowledge  of  the  action 

i  British  Medical  Journal,  1886.  *  U.  S.  Dispensatory,  1883. 


DISEASES  OF  THE  OVUM.  471 

of  the  remedy,  and  its  value  must  be  considered  at  present  apocryphal.  The 
dose  of  the  fluid  extract,  the  only  preparation  of  viburnum  which  is  officinal,  is 
from  half  a  teaspoonful  to  one  or  two  teaspoonfuls,  three  times  a  day. 

Some  physicians,  chiefly  in  Italy,  have  recently  recommended  asafoetida,  given 
twice  a  day,  in  threatened  abortion.  The  most  important  means,  however,  will 
be  the  removal  of  the  causes  which  produce  abortion. 

In  most  cases,  if  four  months  have  passed  without  abortion  occurring, 
that  is,  if  a  previous  one -were  before  this  time,  the  probability  is  that 
pregnancy  will  not  be  disturbed,  and  the  patient  may  gradually  resume 
a  moderately  active  life. 

TREATMENT  OF  BEGINNING  ABOETION.  Here  the  characteristic 
symptoms,  to  wit,  hemorrhage  and  uterine  contractions,  are  present ; 
under  only  three  conditions  is  the  abortion  inevitable;  the  first  is  the 
death  of  the  embryo  or  foetus;  the  second,  detachment  of  a  large  por- 
tion of  the  ovum ;  and  the  third,  rupture  of  the  ovum.  But  it  is  in 
exceptional  cases  the  physician  can  know  at  the  beginning  that  any  one 
of  these  conditions  is  present,  and  therefore  his  duty  in  all  cases  is  to 
endeavor  to  arrest  the  miscarriage.  The  patient  should  at  once  lie 
down,  her  clothing  being  quite  loose,  the  bed  moderately  hard,  and  she 
should  be  only  lightly  covered  ;  her  drinks  should  be  cold — iced  lemon- 
ade is  very  commonly  given.  Twenty  drops  of  laudanum  with  half  a 
teacup  of  warm  water  should  be  at  once  injected  iuto  the  rectum,  or  an 
equivalent  amount  of  opium  in  the  form  of  a  suppository  may  be  used. 
The  purpose  sought  to  be  accomplished  by  the  opiate  is  to  lessen  the 
irritability  and  arrest  the  contractions  of  the  uterus ;  it  is  claimed  by 
some  that  the  pregnant  woman  bears  this  remedy  much  better  than  when 
not  pregnant.  If  the  contractions  have  not  decidedly  abated  in  one 
hour,  the  injection  or  suppository  is  repeated,  and  again  if  necessary  at 
the  end  of  the  second  hour,  and  still  again  at  the  end  of  the  third  hour. 
If  the  patient  is  very  nervous  and  restless,  twenty  to  thirty  grains  of 
chloral  may  be  added  to  one  of  the  opiate  injections,  and  then  the  vehicle 
should  be,  not  warm  water,  but  the  yelk  of  an  egg  and  some  warm 
milk.  When  opiates  are  given  freely,  it  is  quite  possible  that  retention 
of  urine  will  follow,  and  if  this  is  the  case  the  catheter  must  be  used 
as  needed,  twice  or  thrice  in  the  twenty-four  hours ;  the  employment  ot 
the  instrument  is  preferable  to  allowing  the  patient  to  sit  up  to  urinate. 
The  opium  may  be  continued  from  day  to  day  as  long  as  there  is  any 
hope  of  arresting  the  abortion.  Meantime,  once  in  two  days  the  bowels 
should  be  opened  by  a  warm-water  injection,  or  by  a  mild  laxative. 
Supposing  the  pain  and  hemorrhage  to  cease,  it  is  better  for  the  patient 
to  remain  in  bed  for  three  or  four  days  after  this  cessation ;  when  she 
gets  up  she  should  only  gradually  resume  her  usual  habits  of  life,  even 
then  as  an  experiment,  and  prepared  to  return  to  bed  at  the  first  recur- 
rence of  the  former  symptoms.  Unfortunately,  in  the  majority  of  cases, 
the  pains  and  hemorrhage  do  not  cease,  or  having  stopped  they  return, 
and  the  abortion  is  apparently  inevitable,  or  the  flow  may  be  so  great 
that  its  arrest  is  necessary  without  regard  to  the  continuance  of  the 
pregnancy. 

TREATMENT  OF  INEVITABLE  ABORTION.  Two  indications  are  pre- 
sented— stop  the  bleeding  and  empty  the  uterus.  The  application  ot 


472  THE  PATHOLOGY  OF  PREGNANCY. 

cloths  wrung  out  of  ice-water,  to  the  vulva,  to  the  lower  part  of  the 
abdomen,  and  to  the  upper  part  of  the  thighs,  has  been  recommended; 
but  apart  from  the  uncertainty  of  this  use  of  cold,  such  applications 
may  chill  the  patient,  and  will  make  her  uncomfortable,  and  may  cause, 
if  there  be  liability  to  either,  an  attack  of  bronchitis  or  of  rheumatism. 
Vaginal  injections  of  very  hot  water  are  to  be  preferred,  both  for 
hsemostasis  and  exciting  uterine  action.  If  the  os  be  sufficiently  dilated 
to  permit  immediate  and  complete  evacuation  of  the  uterine  cavity,  it 
should  be  done.  And  to  this  end  firm  pressure  is  made  with  one  hand 
through  the  abdominal  wall  upon  the  uterus,  while  in  some  cases  one 
or  two  fingers  may  be  introduced  into  the  uterine  cavity  to  assist  in  the 
delivery  of  its  contents,  the  greatest  care  being  taken  to  avoid  rupture 
of  the  ovum,  if  this  be  still  entire. 

In  case,  however,  the  os  is  but  little  open,  some  advise  dilatation,  especi- 
ally by  means  of  Barnes's  dilators ;  Dr.  Murphy,  of  Sunderland,  for 
example,  rejects  the  vaginal  tampon,  and  uses  them  as  a  most  efficient 
uterine  tampon,  not  only  arresting  the  hemorrhage,  but  making  possible 
and  hastening  a  complete  delivery. 

The  most  valuable,  the  safest,  and  most  certain  means  of  arresting 
the  hemorrhage  generally  available  is  the  tampon.  Of  course  the  tam- 
pon can  be  best  applied  by  using  Sims' s  speculum,  but  this  is  not  essen- 
tial. The  following  method  may  be  satisfactorily  employed  in  almost  all 
cases.  The  vagina  should  be  washed  out  with  an  antiseptic  injection 
and  the  bladder  emptied ;  let  the  patient  lie  on  her  back  with  flexed 
legs  and  thighs ;  the  practitioner  having  provided  a  number  of  balls  of 
absorbent  cotton  about  the  size  of  a  hulled  walnut,  and  some  iodoform 
in  powder,  or  a  solution  of  carbolic  acid,  now  separates  the  labia  with 
two  fingers  of  one  hand,  then  by  means  of  an  ordinary  dressing- forceps 
in  the  other  hand,  carries  one  and  then  another  of  the  cotton  balls  up 
into  the  vaginal  vault,  firmly  pressing  them  around  the  cervix ;  the 
balls  first  introduced  should  be  covered  with  iodoform  or  dipped  in 
the  carbolized  water.  After  filling  the  vaginal  vault  with  the  cotton, 
another  layer  of  balls  is  firmly  placed  beneath  the  first,  and  still  one 
or  two  beneath  that,  until  at  least  the  upper  third  of  the  vagina  is  com- 
pletely filled,  and  the  os  uteri  covered  over.  The  use  of  an  astringent 
solution,  such  as  one  of  the  salts  of  iron,  is  unnecessary,  for  by  no 
possibility  can  one  drop  of  fluid  come  in  contact  with  the  bleeding 
surface,  and  needless  irritation,  even  inflammation  and  sloughing  of  the 
vagina,  may  occur  if  a  concentrated  solution  is  employed. 

Instead  of  balls  of  cotton,  strips  of  iodoform  or  of  creolin  gauze  .may  be  used. 
I  have  in  some  instances  made  a  vaginal  tampon  by  taking  a  strip  of  absorbent 
cotton,  10  or  12  inches  long  and  about  2  inches  broad ;  let  one  side  of  the  strip 
be  covered  with  a  4  per  cent,  creolin  ointment ;  then  seizing  one  end  of  the  cot- 
ton with  forceps,  while  the  vulval  orifice  is  kept  open,  it  is  carried  up  to  the 
anterior  portion  of  the  vaginal  vault,  and  from  this  as  a  starting-point  alternate 
folds  made  posteriorly  and  anteriorly  until  the  upper  part  of  the  vagina  is  com- 
pletely packed,  a  second  and  a  third  strip  being  used  if  necessary.  The  special 
advantage  of  this  method  of  using  cotton  as  a  tampon  rests  upon  facility  of  appli- 
cation and  of  removal. 

In  only  rare  cases  will  it  be  necessary  to  tampon  the  entire  vagina, 
and  secure  the  packing  by  a  T-bandage.  The  tampon  is  a  perfect  safe- 


DISEASES  OF  THE  OVUM.  473 

guard  against  hemorrhage,  but  it  must  be  of  suitable  material  and 
properly  applied  ;  let  no  practitioner  in  this  or  any  other  case  of  uterine 
hemorrhage  delude  himself  by  trusting  a  tampon  of  sponge.  The  ad- 
vantages of  the  tampon  in  abortion  are,  not  only  in  the  arrest  of  external 
hemorrhage,  but  its  pressure  evokes  uterine  contractions,  and  the  small 
quantity  of  blood  escaping  from  the  detachment  of  the  ovum  is  now 
shut  up  in  the  womb,  and  passes  between  the  former  and  the  uterine 
Avail,  perfecting  the  separation,  and  thus  facilitating  complete  discharge. 
The  tampon  may  be  left  in  place  twelve  or  twenty-four  hours,  perfect 
antisepsis  having  been  observed  in  its  application.  Upon  its  removal 
the  ovum  will  in  many  cases  be  found  in  the  upper  part  of  the  vagina, 
or  it  may  have  entered  the  cervical  canal,  and  so  completely  fill  it  that 
a  repetition  of  the  tampon  is  unnecessary ;  in  the  latter  case  firm  com- 
pression of  the  uterus  may  finish  the  expulsion  of  the  ovum ;  even 
before  the  descent  into  the  canal,  delivery  by  expression  is  sometimes 
successful. 

The  general  practice  is  to  give  ergot  when  there  is  much  hemorrhage; 
but  if  the  cervical  canal  is  undilated,  it  is  claimed  by  some  that  the 
medicine  contributes  quite  as  much  to  the  imprisonment  as  to  the  expul- 
sion of  the  ovum.  This  objection  is  completely  removed  if  the  tampon 
be  used  when  ergot  is  administered.  Ergot  and  the  tampon  are  reme- 
dies that  act  admirably  when  associated  in  these  cases.  The  practitioner 
in  cases  of  miscarriage  in  the  first  three  months  must  be  especially 
careful  not  to  rupture  the  ovum,  for  if  the  amnial  sac  be  opened  there 
is  great  danger  of  the  abortion  being  incomplete.  In  case  hemorrhage 
persists  or  returns,  the  abortion  not  yet  having  taken  place,  the  tampon 
is  to  be  repeated,  and  with  the  repetition  ergot  may  also  be  used. 

While  in  the  great  majority  of  cases  under  this  treatment  the  ovum 
is  expelled  entire,  in  some  the  embryo  or  the  foetus  is  discharged,  but 
the  appendages  retained ;  or  the  case  may  be  one  in  which  the  abortion 
was  begun  by  perforating  or  puncturing  the  membranes.  If  the 
pregnancy  has  continued  as  long  as  four  months,  usually  expression  will 
cause  the  expulsion  of  the  placenta  and  membranes ;  if  necessary,  this 
expulsion  may  be  facilitated  by  digital  or  other  dilatation  of  the  os  uteri. 
These  cases  as  a  rule  do  not  present  serious  difficulties,  though  there  may 
be  delay  and  difficulty  in  completely  emptying  the  womb. 

But  if  a  miscarriage  occurs  in  the  period  from  seven  to  ten  weeks, 
and  immediately  after  the  expulsion  of  the  embryo  the  cervical  canal 
closes,  what  practice  is  to  be  pursued  ?  Some  insist  upon  immediately 
emptying  the  uterus  by  means',  if  necessary,  of  instruments,  either 
forceps,  curettes,1  or  Simon's  spoon.  Certainly  when  miscarriage  is 
incomplete,  there  is  a  possibility  of  serious  dangers,  but,  on  the  other 
hand,  hasty  interference  is  not  free  from  peril ;  the  appendages  are  re- 
tained either  because  still  attached  to  the  uterus,  or  because  of  the  ob- 
stacle presented  by  the  narrowed  cervix.  If  attachment  prevents  their  dis- 
charge, they  are  a  living  part  of  the  uterus,  and  tearing  them  away  in 
itself  is  a  traumatism,  while  rude  efforts  in  this  process  may  inflict  ad- 
ditional traumatism,  and  as  fragments  are  almost  inevitably  left  behind, 

1  I  am  glad  to  read  the  recent  statement  of  Ahlfeld  :  Curetting  is  almost  always  unnecessary. 
Wounds  from  the  curette  are  unavoidable. 


474  THE  PATHOLOGY  OF  PREGNANCY. 

the  detachment  is  incomplete ;  moreover,  their  presence  in  the  uterus 
may  for  a  time  give  rise  to  no  symptoms.1  But,  on  the  other  hand,  if 
partial  or  complete  detachment  has  occurred  there  will  be  hemorrhage ; 
or  if  retention  is  permitted  for  a  day  or  two,  in  addition  to  the  hemor- 
rhage there  may  be  an  offensive  discharge.  Now,  the  indications  for 
active  interference  are  unequivocal,  and  delay  is  perilous.  In  these  cases 
gradual  dilatation  of  the  os  may  be  effected  by  tupelo  tents  or  a  rapid 
dilatation  by  Hegar's  hard-rubber  dilators,  and  this  is  the  preferable 
plan,  the  patient  being  anesthetized  if  thought  best.  After  the  dilata- 
tion the  uterine  cavity  is  disinfected  by  washing  it  out  with  a  3  per  cent, 
solution  of  carbolic  acid  in  warm  water,  and  one  or  two  fingers  made 
aseptic  and  dipped  in  an  antiseptic  fluid — one  teaspoonful  of  creolin,  for 
example,  in  a  pint  of  water — are  passed  into  the  uterine  cavity,  while 
the  other  hand  upon  the  hypogastrium  presses  the  uterus  down  upon 
the  internal  fingers ;  or,  as  advised  by  Dr,  Alexander  R.  Simpson,  the 
uterus  is  drawn  down  to  the  mouth  of  the  vulva  by  the  volsellum,  and 
then  one  or  two  fingers  introduced.  In  either  case  the  membranes  are 
detached  by  the  fingers  and  brought  down  to  the  os ;  in  some  instances 
the  finger  and  thumb  may  be  used  like  a  crab's  claw,  as  Mauriceau 
expressed  it,  to  seize  them  and  draw  them  out. 

But  if  digital  detachment  fails  to  remove  the  remains  of  the  ovum,  I 
have  found  the  following  an  excellent  plan  The  practitioner  has  at 
hand  a  basin  of  warm  carbolized  water,  Churchill's  tincture  of  iodine, 
Emmet's  curette  forceps,  a  uterine  tenaculum,  one  or  more  applicators, 
a  uterine  probe,  absorbent  cotton,  and  a  bivalve  speculum — Neugebauer's 
answers  admirably.  The  patient  now  has  her  hips  brought  to  the  edge 
of  the  bed,  and  the  thighs  and  legs  strongly  flexed  ;  after  the  introduc- 
tion of  the  speculum  and  exposure  of  the  os,  the  tenaculum  is  inserted 
into  the  anterior  lip  from  below  and  firmly  held,  so  as  to  fix  the  womb, 
and  also  used  to  straighten  any  flexion  that  may  be  present ;  next  the 
uterine  probe  is  introduced  to  ascertain  the  size  and  direction  of  the 
uterine  cavity,  after  which  the  blades  of  the  curette  forceps,  first  being 
dipped  in  the  carbolized  water,  are  passed  into  the  uterus,  then  opened, 
the  ends  pushed  on  until  touching  the  uterine  wall,  when  they  are  firmly 
closed  and  withdrawn  ;  upon  withdrawal  they  will  be  found  to  contain 
fragments  of  membranes  which  may  be  removed  by  opening  them  and 
moving  them  to  and  fro  in  the  carbolized  water ;  the  process  is  repeated, 
and  all  parts  of  the  uterine  cavity,  especially  the  vicinity  of  the 
entrance  of  the  oviducts,  thoroughly  explored,  and  membranes  detached 
and  removed.  After  completing  the  removal  of  membranes,  or  placental 
fragments,  the  uterine  cavity  is  swabbed  out  with  the  iodine  solution, 
or,  better,  an  injection  of  iodine  made  with  Braun's  syringe ;  iodine  is 
both  an  excellent  antiseptic  and  uterine  haemostatic. 

1  Charles  says :  We  do  not  advise  immediate  efforts  for  the  removal  of  the  after-birth  in  abor- 
tions before  four  months,  wliLe  after  this  period  we  recommend  acting  as  soon  as  possible  in  the 
artificial  delivery  as  after  labor  at  term.  The  conditions  are  different.  1.  The  danger  from  reten- 
tion is  much  less.  2.  The  introduction  of  the  hand  is  impossible  because  of  the  narrowness  of  the 
cervical  canal  and  the  smallness  of  the  uterine  cavity.  3.  The  dilatation  of  the  orifice  and  the 
introduction  of  instruments  designed  to  extract  the  placenta  are  dangerous,  difficult,  and  painful  ; 
these  instruments  act  blindly,  contuse,-lacerate  the  uterine  walls,  and  rarely  succeed  in  removing 
all  the  secundines,  but  almost  always  cause  metritis.  In  a  word,  the  danger  from  retention  is 
much  less  than  that  of  extraction. — Journal  d'Accouchements,  June,  1885. 


DISEASES  OF  THE  OVUM.  475 

Doubtless  some  will  think  that  the  practice  advised  in  incomplete  abor- 
tion of  the  earlier  weeks,  when  there  is  closure  of  the  cervical  canal  after  the 
expulsion  of  the  embryo  or  foetus,  and  no  symptoms  demand  interference,  too 
conservative.  But  I  can  fully  adopt  the  words  of  that  wise  obstetrician,  the  late 
Dr.  Churchill,  "  Longer  experience  has  made  me  less  fearful  of  leaving  these 
cases  to  nature,  and  more  unwilling  to  interfere  hastily."  The  probability  is, 
that  they  will  end  within  a  few  days  by  the  spontaneous  expulsion  of  the  uterine 
contents ;  meantime  the  practitioner  carefully  watches  the  case,  directs  antisep- 
tic vaginal  injection  twice  a  day,  and  is  ready  to  meet  any  dangerous  symptom 
and  to  assist  nature's  process ;  his  position  is  not  that  of  simple  expectation,  but 
of  armed  expectation,  as  a  French  obstetrician  has  expressed  it. 

It  is  satisfactory  to  the  writer  to  know  that  the  conservative  treatment — con- 
servative in  opposition  to  the  radical  methods  advocated  by  many  authors  in 
recent  years — presented  in  previous  editions  of  this  work  and  now  repeated,  is 
in  perfect  correspondence  with  that  of  Winckel  in  his  work  upon  obstetrics. 
This  eminent  and  able  practitioner,  with  an  experience  which  is  the  fortune  of 
few,  uses  the  following  language  :l  "  I  maintain  that  if,  in  an  abortion  or  imma- 
ture labor,  fragments  of  foetal  membranes  or  placenta  have  remained  behind,  we 
are  justified  and  obliged  to  proceed  to  operative  interference  only  when  there  are 
severe  hemorrhages  from  the  uterus,  or  fever  or  sloughing  occurs.  In  the  absence 
of  these  indications  I  am  strongly  opposed  to  cleansing  the  uterus,  either  by 
hand  or  by  instruments,  because  this  method  furnishes  no  guaranty  against  small 
fragments  being  left  behind  and  against  direct  inoculation  of  sanious  matter  into 
existing  lesions.  If  the  placenta  remain  behind  and  the  inetrnal  os  closes,  or 
permit  at  most  the  introduction  of  one  finger,  or  even  if  an  exudation  can  be 
detected  in  the  neighborhood  of  the  uterus,  we  must  desist  from  any  attempts  at 
entering  the  uterus,  but  should  administer  ergot,  irrigate  the  uterus  daily  through 
a  Fritsch  or  Budin  catheter  with  an  antiseptic  fluid,  such  as  solutions  of  boric 
acid,  carbolic  acid,  or  of  potassic  permanganate,  or  chlorine-water,  and  as  a  rule 
we  will  find  that  in  from  two  to  ten  days  the  placenta  is  completely  and  safely 
expelled." 

The  course  in  incomplete  abortion2  advised  by  Tarnier  and  Budin  is  also  con- 
servative. 

Last  year  Professor  Schauta,  of  Vienna,  made  a  valuable  contribution  to  the 
subject  of  the  treatment  of  abortion ;  some  of  his  directions  in  the  manage- 
ment of  abortion  will  now  be  presented.  He  condemns  active  intervention  at 
first,  so  strongly  advised  by  some  authors,  and  is  content  with  meeting  the  first 
symptom,  hemorrhage,  by  a  vaginal  tampon  of  iodoform  gauze ;  it  is  not  neces- 
sary to  use  the  speculum.  If  after  introducing  the  tampon  the  pains  are  severe 
enough  to  cause  the  expulsion  of  the  ovum,  the  latter  will  be  found  upon  re- 
moval of  the  former.  But  the  contractions  not  having  effected  this  expulsion, 
the  tampon  is  removed  at  the  end  of  twenty-four  hours,  and  after  its  removal  the 
neck  is  found  dilated  or  not,  and  the  hemorrhage  has  ceased  or  continues  It 
the  neck  is  not  dilated  and  the  hemorrhage  has  ceased,  no  immediate  interven- 
tion, but  wait — possibly  abortion  may  not  occur. 

But  if  the  neck  is  partially  dilated,  and  bleeding  continues,  a  fresh  tampon, 
and  this,  if  necessary,  is  replaced  by  another  at  the  end  of  twenty-four  hours. 
In  acting  thus  the  ovum  is  completely  detached  and  is  entirely  expelled.  Occa- 
sionally, after  tamponing  several  days,  it  may  happen  that  the  neck  will  admit 
two  fingers,  nevertheless  the  ovum  Remains.  This  fact  shows  that  the  ovum  is 
adherent,  and  its  adhesions  must  be  artificially  ruptured  ;  for  this  end  two  fingers 
are  passed  into  the  uterus,  pressed  down  so  that  the  fingers  reach  to  its  fundus, 
and  then  they  are  carefully  used  to  detach  the  ovum,  when  the  hand  is  with- 
drawn and  simple  pressure  upon  the  uterus  usually  causes  expulsion  of  the  ovum  ; 
if  this  does  not  occur,  use  forceps,  and  if  bleeding  follows  tampon  the  uterus  with 
iodoform  gauze,  the  tampon  remaining  twenty-four  hours.  In  those  cases  to 
which  the  practitioner  is  first  called,  when  the  uterus  has  lessened  in  size,  the 
neck  not  dilated,  and  hemorrhage  continues,  there  are  fragments  of  the  mem- 
branes retained,  and  dilatation  is  necessary,  preferably  by  Hegar's  dilators.  Let 
the  finger  be  used  after  this  dilatation  to  remove  the  retained  fragments,  and  if 

1  Edgar's  translations. 

-  Trait6  de  1'Arte  des  Accouchements,  tome  deuxieme. 


476  THE  PATHOLOGY  OF  PREGNANCY. 

not  thus  succeeding,  then  the  curette,  guiding  the  instrument  by  the  finger  and 
using  it  only  upon  those  parts  where  there  are  such  adherent  fragments  ;  he  con- 
demns blind  general  curetting  the  endoinetrium.  I  am  very  glad  to  introduce 
this  condensed  statement  of  Professor  Schauta's  method ;  I  hope  his  practice  and 
counsel  will  do  something  toward  checking  the  radical  treatment  of  abortion, 
which  has,  in  my  opinion,  come  too  much  in  vogue. 

AFTER-TREATMENT.  The  patient  remains  in  bed  at  least  a  week 
after  a  miscarriage,  for  frequently  permanent  invalidism  is  caused  by 
neglect  of  proper  care  at  this  time. 

MISSED  ABORTION.  Sinclair,1  in  a  paper  upon  this  subject,  classifies 
cases  of  missed  abortion  as  follows  :  (1)  those  in  which  expulsion  occurs 
spontaneously  before  the  end  of  pregnancy ;  (2)  those  in  which  expul- 
sion takes  place  at  or  about  the  full  period  of  pregnancy ;  and  (3)  those 
in  which  the  ovum  is  retained  beyond  the  full  period  of  pregnancy. 
He  shows  from  statistics  that  the  accident  is  very  rare  in  primigravidae  ; 
he  also  calls  attention  to  the  fact  that  while  in  a  large  number  of  cases 
the  expulsion  of  the  ovum  is  apparently  spontaneous,  in  others  a  slight 
disturbance,  in  one  instance  a  vaginal  examination,  determines  the  ex- 
pulsion, remarking  "  It  would  seem  as  if  there  was  a  kind  of  equilibrium 
between  the  retentive  and  expulsive  forces,  and  that  this  equilibrium 
could  be  readily  upset  by  any  influence  capable  of  slightly  increasing 
the  force  of  the  uterine  contractions." 

The  indication  in  missed  abortion  is  to  empty  the  uterus.  In  some 
cases,  as  in  one  reported  by  Matthews  Duncan,  the  introduction  of  a 
bougie  will  be  sufficient  to  excite  the  uterine  contractions ;  in  others 
it  may  be  necessary  to  dilate  the  os  uteri  with  tupelo,  or  with  Hegar's 
dilators. 

In  concluding  the  subject,  a  single  word  upon  criminal  abortion. 
The  temptations  to  this  offence  probably  come  to  every  physician.  He 
will  be  appealed  to  by  the  unfortunate  victim  of  man's  passion  and 
perfidy  to  save  her  and  her  family  from  disgrace,  and  his  sympathies  will 
unite  with  the  teaching  of  some  utilitarian  theories  of  morals  to  stifle 
the  voice  of  conscience ;  family  friendship  will  be  plead  by  the  married 
woman  already  a  mother,  who  does  not  wish  to  have  any  more  chil- 
dren ;  or  finally,  the  baser  motive  of  avarice  will  be  invoked,  and  he 
may  be  promised  a  far  more  liberal  sum  than  led  Judas  to  be  chief 
contributor  to  the  crime  of  the  ages.  But  he  must  turn  a  deaf  ear  to 
all  these  appeals.  "  Heart's  blood  weighs  too  heavily,"  and  let  him 
beware  of  violating  both  human  and  Divine  law,  no  matter  how  great 
the  temptation. 

1  Journal  of  the  British  Gynecological  Society,  1887. 


SECTION  II. 

THE  PATHOLOGY  OF  LABOR. 


INTRODUCTORY.  The  pathology  of  labor  includes  anomalies  of  the 
forces  that  expel  the  ovum  and  secure  subsequent  normal  contraction  of 
the  uterus ;  anomalies  of  the  passage  through  which  the  foetus  is  trans- 
mitted, and  anomalies  of  the  foetus  itself,  whether  deviations  in  position, 
in  size,  or  in  form  ;  finally,  the  accidents  which  may  occur  in  a  labor, 
or  immediately  follow  it,  such  as  rupture  of  the  uterus  and  post-partum 
hemorrhage,  must  be  considered.  Of  course,  anomalies  of  the  passage 
will  embrace  deformities  of  the  pelvis,  just  as  the  therapeutics  required 
in  certain  pathological  conditions  will  include  obstetric  operations. 

I.  Anomalies  of  the  Forces  concerned  in  Labor.  These  anomalies 
relate  chiefly  to  the  uterine  force.  This  force  may  be  abnormal  by 
excess,  by  deficiency,  or  by  perversion. 

a.  Excess  of  uterine  force.  In  those  cases  in  which  the  uterine  con- 
tractions are  strong  and  recur  rapidly  the  labor  has  a  speedy1  end  with- 
out danger  to  mother  or  child,  provided  the  latter  present  favorably, 
and  the  birth-canal  offers  no  serious  obstruction,  and  suitable  precautions 
are  taken.  But  in  the  absence  of  proper  care  delivery  may  surprise  the 
woman  while  she  is  standing,  or  while2  she  is  upon  a  commode  or  in 
the  water-closet,  and  the  child  be  injured,  the  cord  torn,  the  uterus 
inverted,  or  relaxation  follow  the  violent  uterine  action,  and  hemorrhage 
result.  Again,  if  the  os  or  the  perineum  does  not  yield  readily,  a  tear 
in  one  or  both  may  occur  from  excessive  uterine  action ;  an  injury  to 
the  former  is  less  likely  to  occur  than  to  the  latter. 

Emphysema  of  the  Neck,  Face,  and  Chest.  If  voluntary  efforts  in  labor  are  very 
great,  especially  in  primiparse,  it  sometimes  happens  that  rupture  of  some  of  the 
air  vesicles  occurs,  and  emphysema  of  the  neck,  face,  and  chest  follows.  Blundell3 
has  spoken  of  the  condition  as  follows  :  "  It  is  not  frequently  that  a  disruption 
of  the  larger  air-tubes  occurs  in  the  progress  of  laborious  parturition ;  yet  this 
accident  is  sometimes  observed,  the*trachea  or  bronchi  giving  way.  After  much 
exertion,  the  neck  and  face  swell,  from  the  hurrying  of  the  circulation,  an  ery- 
thematous  flush  of  the  integuments  is  produced,  and  at  first  glance  the  patient 
appears  to  labor  under  a  sudden  attack  of  erysipelas ;  the  nature  of  the  swelling 
manifesting  itself  on  making  an  examination  by  the. usual  crepitus  perceived  on 
compressing,  and  lightly  shampooing  the  skin  with  the  tips  of  the  fingers. 
Should  emphysema  occur,  delivery  is  desirable.  To  retain  the  breath  and  force 
down  is  likely  to  aggravate  the  disease,  so  that  the  emission  of  the  voice  may  be 

1  The  old  authors  described  it  as  partus  prxcipitalus,  precipitate  birth. 

2  If  a  woman  is  delivered  standing,  it  is  rare  that  the  child  is  seriously  injured  by  falling  on  the 
•floor,  because  the  force  of  the  fall  is  broken  by  the  limbs  of  the  mother  and  by  the  resistance  of  the 

cord,  though  the  latter  be  ruptured  by  the  sudden  strain. 

3  Principles  and  Practice  of  Obstetricy. 


478  27/7!,'  PATHOLOGY  OF  LABOR. 

recommended.  After  delivery,  if  I  may  judge  from  the  single  case  brought 
under  my  notice,  the  aperture,  seldom  capacious,  heals  spontaneously,  and  with- 
out inflammation  the  air  is  absorbed." 

The  swelling  and  the  characteristic  crepitation  clearly  indicate  the  nature  of 
the  accident.  The  emphysema,  if  not  very  great,  disappears  spontaneously  in 
five  or  six  days.  Of  course,  the  patient  is  not  permitted  to  continue  any  volun- 
tary effort,  but  the  labor  must  be  terminated  by  the  sole  force  of  uterine  con- 
tractions, or  by  instrumental  delivery.1 

As  has  been  previously  stated,  very  active  uterine  contractions  are  not 
to  be  regarded  as  pathological  in  a  normal  condition  of  the  birth-canal, 
and  normal  presentation  and  size  of  the  foetus,  and,  therefore,  usually 
require  no  direct  interference.  The  woman  must  be  in  bed,  and  lying 
upon  one  or  the  other  side ;  she  is  advised  not  to  make  any  bearing- 
down  efforts,  but  keep  her  mouth  open,  refrain  from  pressing  against 
any  object  with  her  feet,  or  grasping  one  with  her  hands  during  a 
uterine  contraction.  But  if  the  unyielding  condition  of  any  portion  of 
the  birth-canal  renders  tearing  probable  from  the  rapidity  of  the  labor, 
free  inhalation  of  chloroform  must  be  used  to  moderate  the  uterine 
force.  Care  must  be  taken  in  the  third  stage  of  labor  to  see  that  the 
uterus  undergoes  its  normal  retraction. 

In  some  cases  violent  contractions  of  the  uterus  may  be  the  consequence  of 
too  early  rupture  of  the  membranes,  or  frequent  and  rough  examinations,  or 
improper  efforts  to  dilate  the  os  with  the  fingers  or  other  mechanical  means,  in 
short,  of  "  meddlesome  midwifery  ";  to  mention  the  origin  of  the  evil  is  to  sug- 
gest its  prevention. 

b.  Deficiency  of  uterine  force.  Here  the  uterine  contractions  fail  in 
intensity,  in  duration,  and  in  frequency;  this  condition  results  in 
"  tedious  labor."  Feebleness  of  uterine  contractions  is  much  more  fre- 
quently met  with  than  the  condition  just  described,  and  it  may  occur 
in  any  one  of  three  stages  of  labor,  though  most  frequent  in  the  first. 
It  varies  in  degree  and  continuance,  and  may  end  in  an  actual  cessation 
of  uterine  activity,  which  is  commonly  known  as  inertia  of  the  uterus. 
The  immediate  danger  to  the  mother  from  weak  uterine  contractions  is 
greatest  in  the  third  stage  of  labor — for  then,  hemorrhage  is  the  inevitable 
consequence.  Delay  in  the  first  stage  of  labor  if  rupture  of  the  mem- 
branes has  not  occurred  is  not  attended  with  risk  to  the  child,  or 
immediate  peril  to  the  mother ;  indeed,  in  very  many  cases  she  suffers 
no  injury,  immediate  or  remote,  from  this  delay.  But  if  the  amnial 
liquor  has  been  discharged  some  risk  comes  to  the  foetus,  though  prob- 
ably this  is  not  usually  so  great  as  has  been  thought,  for  complete  empty- 
ing of  the  liquor  is  exceedingly  improbable ;  especially  if  the  vertex  pre- 
sents, there  usually  remains  filling  up  the  interstices  in  the  ftetal  ovoid 
a  considerable  quantity  of  the  fluid,  so  that  the  cord  is  protected 
from  injurious  pressure.  Most  practitioners  of  even  a  few  years' 
obstetric  experience  have  met  with  cases  in  which  spontaneous  rup- 
ture of  the  membranes  occurred  twenty-four  hours,  or  even  three  or 

1  Tn  the  British  Medical  Journal,  October  24,  1885,  a  case  of  emphysema  in  labor  is  reported,  in 
which  the  entrance  of  air  into  the  connective  tissue  of  the  neck  and  upper  part  of  the  chest,  is 
supposed  to  have  occurred  through  a  small  denuded  surface  about  the  middle  of  the  right  cheek 
in  the  cavity  of  the  mouth— certainly  a  very  singular  hypothesis. 


INTR  OD  UCTION.  479 

four  days  before  labor  began,  yet  in  most  instances  it  ended  in  the 
birth  of  a  living  child.  Delay  in  the  second  stage  of  labor  is  serious 
for  both  mother  and  child,  for  supposing  the  head  to  have  entered  the 
pelvic  cavity,  it  may  produce  by  continued  pressure  upon  the  mother's 
soft  parts  inflammation  and  sloughing,  with  consequent  rectal  or 
vesical  fistula? ;  even  if  these  accidents  do  not  happen,  the  injury  to 
tissues  opens  the  door  for  septic  infection  ;  the  child  suffers  from  pro- 
longed pressure,  and  fatal  asphyxia  is  the  not  uncommon  consequence. 
The  mother's  life  is  endangered  by  the  exhaustion  which  follows  long- 
continued  powerless  labor. 

In  some  cases  at  the  close  of  the  first  stage  of  labor,  and  immediately  after  the 
evacuation  of  the  liquor  ainnii,  a  pause  occurs  in  the  labor ;  there  is  an  absence 
of  uterine  contractions,  or  these  are  very  feeble,  and  this  condition  may,  though 
it  is  not  common,  last  some  time  unless  means  are  used  to  evoke  the  languishing, 
or  the  delayed  uterine  force.  The  patient,  usually  a  multipara,  is  herself  sur- 
prised that  the  pains  have  ceased ;  the  practitioner,  upon  making  a  vaginal 
examination,  finds  the  head  still  within  the  uterus,  the  cervix  perfectly  relaxed, 
and  its  walls  hanging  in  loose  folds,  and  a  perfectly  normal  condition  of  the 
remaining  portion  of  the  birth-canal ;  a  few  vigorous  pains,  assisted  by  abdominal 
efforts,  are  apparently  all  that  is  needed  to  effect  the  expulsion  of  the  child. 
Longer  labor-pauses  sometimes  occur  before  the  discharge  of  the  amnial  liquor ; 
labor  has  come  on,  and  some  degree  of  dilatation  of  the  os  been  accomplished ; 
then  uterine  action,  which  has  been  manifest  for  hours,  gradually  ceases,  and  the 
patient  goes  to  sleep,  often  to  the  surprise,  if  not  the  disappointment,  of  attend- 
ants, who  expected  that  in  a  short  time  the  labor  would  be  over ;  twenty-four 
hours  may  pass  before  the  labor  is  resumed.  Such  cases  are  not  to  be  regarded 
as  pathological ;  the  cessation  of  uterine  contractions  is  very  different  from  that 
observed  when  the  uterus  has  for  hours  vainly  struggled  against  some  invincible 
obstacle,  until  its  force  is  exhausted.  The  condition  last  mentioned  is  most 
frequent  after  the  rupture  of  the  membranes,  and  in  the  second  stage  of  labor. 

Voluntary  force  may  be  feeble,  the  abdominal  contractions  failing  to  contribute 
their  part  to  the  progress  of  the  foetus.  This  failure,  in  the  majority  of  cases, 
occurs  when  uterine  contractions  are  attended  with  much  suffering  ;  the  patient 
refrains  from  effort  lest  she  may  add  to  that  suffering.  Again,  voluntary  effort 
may  fail  from  the  general  weakness  of  the  patient  or  from  her  being  profoundly 
narcotized. 

CAUSES  OF  WEAK  PAINS.  Failure  of  uterine  force  may  arise  from 
previous  exhaustion,  or  from  that  caused  by  protracted  labor  ;  the  uterus 
has  grown  weary  in  its  work,  and  falls  into  a  condition  of  inertia.  It 
may  be  the  result  of  deficient  uterine  innervation,  or  it  may  be  caused 
by  excessive  uterine  disteution,  as  from  polyhydramnios,  or  from  the 
presence  of  more  than  one  foetus ;  the  upper  portion  of  the  uterus  being 
thus  thinned,  it  cannot  triumph  over  the  normal  resistance  of  the  os. 
A  full  bladder  or  a  loaded  rectum  may  hinder  normal  uterine  action. 
Kleinwachter  has  drawn  attention  to  the  fact  that  failure  of  uterine 
contractions  may  result  from  an  artificial  cause,  as,  for  example,  if 
during  the  course  of  labor  the  forceps  is  applied  and  unsuccessful 
attempts  at  extraction  are  made,  the  labor-activity  may  be  permanently 
interrupted.  Mental  influences  may,  temporarily  at  least,  cause  the 
labor  to  lag,  the  uterine  contractions  becoming  weak  and  inefficient.  A 
woman  depressed  by  fear  or  anxiety,  or  offended  by  the  presence  of 
someone  to  whom  she  has  an  antipathy,  or  wounded  by  the  unkindness 
of  another  the  nearest  to  her,  and  to  whom  she  ought  to  be  the  dearest 


480  THE  PA THOLOQ  Y  OF  LABOR. 

iu  this  her  hour  of  sore  trial,  and  possibly  of  great  peril,  may  have 
weak  uterine  contractions  thus  caused. 

PROGNOSIS.  This  depends  upon  the  stage  of  labor  in  which  feeble 
pains  occur ;  upon  whether  the  membranes  have  been  ruptured  or  are 
still  entire  ;  upon  the  causes  of  the  condition  ;  upon  the  general  state  of 
the  mother,  and  upon  that  of  the  child.  In  the  first  stage  of  labor,  the 
membranes  being  unruptured,  as  a  rule  the  child  does  not  suffer  ;  but 
the  prolongation  of  the  first  stage  is  iu  many  cases  not  a  matter  of  indif- 
ference as  far  as  the  mother  is  concerned,  for  she  may  be  deprived  of 
sleep,  become  discouraged  by  the  delay,  and  exhausted  by  her  fruitless 
suffering,  which  exceptionally  continues  for  several  days.  Charpentier 
mentions  a  case  in  his  practice  in  which  dilatation  was  not  accomplished, 
notwithstanding  all  means  employed,  until  five  days  ;  the  delivery  was 
then  made  by  forceps.  In  Greek  mythology  a  case  in  which  labor 
lasted  nine  days  is  given.1 

The  gravity  of  the  condition,  if  it  occurs  in  the  second  or  in  the  third 
stage  of  labor,  has  been  sufficiently  pointed  out. 

TREATMENT.  Here  we  must  carefully  distinguish  between  physio- 
logical and  pathological  labor-pauses,  for  in  the  former  we  abstain  from 
active  interference,  while  in  the  latter  it  may  be  imperative,  and  often 
must  be  prompt.  Again,  for  their  wise  treatment  a  recognition  of  the 
causes  of  weak  pains  is  essential,  and  also  the  period  in  labor  of  their 
occurrence,  and  the  condition  of  mother  and  of  «hild.  If  the  con- 
tractions are  attended  with  excessive  suffering,  we  have  in  chloral 
one  of  the  best  agents  for  its  relief.  If  feeble  uterine  contractions 
occur  in  the  first  stage,  wearying  and  exhausting  the  patient,  while 
dilatation  of  the  os  almost,  if  not  quite,  fails,  the  membranes  being 
unruptured,  we. may  imitate  nature's  action  in  many  cases,  and  create 
a  temporary  labor-pause  by  the  administration  of  morphine;  after  a 
sleep  of  a  few  hours  it  is  not  unusual  for  uterine  action,  thus  tem- 
porarily suspended,  to  return  with  normal  vigor.  The  practitioner 
should  know  that  the  bladder  and  rectum  are  completely  emptied. 
When  uteriue  contractions  fail  from  deficient  iunervatiou  of  the  uterus, 
a  change  of  position,  especially  from  the  recumbent  to  the  erect,  or 
walking  for  a  time,  may  produce  a  favorable  effect.  Similar  action 
may  be  accomplished  by  a  stimulating  rectal  injection,  or  by  hot-water 
vaginal  injections  ;  taking  a  moderate  quantity  of  food,  a  cup  of  hot  tea, 
or  a  glass  of  hot  lemonade  is  in  some  cases  followed  by  increase  of  uterine 
action.  If  the  uterus  fails  to  contract  because  of  its  excessive  distention, 
rupture  of  the  membranes  is  indicated,  though  the  os  is  only  partially 
dilated,  but  dilatable.  Even  if  there  may  not  be  obviously  great 
uterine  distention,  partial  evacuation  of  the  amnial  liquor  is  often  fol- 
lowed by  vigorous  uterine  action.  But  this  should  only  be  doue  if  the 
presentation  is  normal  and  the  position  favorable,  and  the  os  at  least  half- 
dilated  and  dilatable.  Hasty  intervention  is,  in  the  majority  of  cases, 

1  Latona,  pregnant  by  Jupiter,  and  her  labor  at  hand,  was  pursued  by  jealous  Juno,  and  at  last 
found  secure  retreat  in  the  island  of  Delos.  Her  labor  lasted  nine  days  and  nine  nights,  when, 
seizing  hold  of  a  palm  tree,  she  gave  birth  to  Apollo,  the  god  of  medicine  and  of  music.  The  posi- 
tion she  took  to  end  a  protracted  and  difficult  labor  might  be  adduced  as  an  argument  in  favor  of 
delivery  being  effected  while  the  woman  is  erect  or  leaning  forward.  It  may  also  be  mentioned 
that  from  the  legend  we  learn  that  Artemis,  the  twin  sister  of  Apollo,  was  born  twenty-four  hours 
after — an  interval  that,  as  has  been  previously  stated,  may  sometimes  occur  in  the  birth  of  twins. 


ANOMALIES  OF  FORCE.  481 

more  dangerous  than  expectation.  The  introduction  of  Braun's  colpeu- 
ryuter  into  the  vagina,  or  of  a  flexible  bougie  into  the  uterus,  placing  it 
between  the  ovum  and  the  uterine  wall,  has  been  used  for  the  purpose 
of  exciting  uterine  action,  and  each  has  sometimes  been  successful.  But, 
of  course,  if  these  means  are  used  very  strict  antisepsis  must  be  observed. 
Friction  of  the  uterus  by  the  hand  upon  the  abdominal  wall  may  sometimes 
be  useful.  Runge  commends  an  entire  bath,  temperature  of  95°  F., 
continued  for  one-half  to  three-quarters  of  an  hour  in  cases  of  prolonged 
labor,  especially  if  the  temperature  increases,  the  general  condition  being 
thereby  improved  and  the  uterine  activity  revived. 

The  use  of  the  forceps  in  the  first  stage  of  labor  after  the  rupture  of  the  mem- 
branes, not  for  the  purpose  of  extraction,  but  simply  to  bring  the  head  down  so 
as  to  press  upon  the  os  uteri  during  uterine  contractions,  and  effect  dilatation, 
has  been  advocated,  in  this  country  especially,  by  the  late  Albert  H.  Smith,1  and 
by  Professor  Isaac  E.  Taylor.2  The  former  has  given  the  following  directions  as 
to  this  use  of  the  forceps :  When  the  os  uteri  is  sufficiently  dilated  to  allow  the 
introduction  of  the  blades,  they  may  be  carefully  applied,  and  during  each 
uterine  contraction  the  head  may'be  drawn  down  gently,  and  with  as  little  com- 
pression as  may  be  required  to  keep  the  blades  in  place.  We  have  then  nature's 
own  dilator,  supplemented  by  art  simply  for  the  increase  of  its  powers,  without 
any  change  in  the  method  of  action,  no  new  plan  of  operation  being  introduced. 
The  application  of  the  forceps  before  the  os  is  dilated  can  only  in  exceptional 
cases  be  proper.  Digital  dilatation  of  the  os  uteri  will  generally  prove  in  cases 
demanding  intervention,  after  spontaneous  and  premature  rupture  of  the  mem- 
branes, a  better  method  than  the  use  of  the  forceps,  at  least  in  the  hands  of  the 
majority  of  practitioners.  Dilatation  by  means  of  rubber  bags  may  in  some 
cases  be  substituted  for  that  by  the  fingers.  Artificial  dilatation  can,  as  a  rule, 
be  more  readily  effected  if  chloral  be  first  given.  In  labor  delayed  by  insufficient 
uterine  contractions  foetal  expression  has  been  proposed  by  Kristeller,3  and 
advocated  especially  by  him  and  by  Suchard,4  though  Kleinwachter  states  that 
it  accomplishes  no  more  than  friction  of  the  fundus  of  the  uterus. 

The  following  are  the  directions  given  by  Kristeller  for  the  applica- 
tion of  this  method : 

The  patient  lies  upon  her  back,  near  the  side  of  the  bed ;  by  percussion  and 
palpation  the  limits  of  the  uterus  are  defined,  the  neighboring  organs  are 
isolated,  and  the  intestinal  folds  separated.  If  the  uterus  incline  too  far  ante- 
riorly or  laterally,  it  is  brought  into  the  axis  of  the  inlet.  It  is  then  embraced 
by  the  hands,  their  cubital  border  being  directed  toward  the  pelvis,  and  their 
palmar  face  applied  to  the  sides  and  to  the  fundus  of  the  uterus,  the  thumbs 
being  upon  the  anterior  face.  The  fingers  are  now  directed  as  far  as  possible 
behind  the  uterus ;  this  succeeds  very  easily  in  the  case  of  a  multipara  whose 
abdomen  is  relaxed  and  yielding,  and  in  a  pluripara  after  the  birth  of  one  child. 
Next  press  gently  the  abdominal  walls  against  the  uterus  thus  embraced  at  the 
superior  part ;  gradually  increase  the  pressure ;  after  keeping  up  this  pressure 
for  a  certain  length  of  time,  it  should  be  gradually  diminished.  The  pressure 
upon  the  fundus  of  the  uterus  should  be  directed  from  above  below,  while  that 
upon  the  sides  converges  toward  the  axis  of  the  organ.  The  duration  of  the 
compression  will  vary  from  five  to  eight  minutes;  it  may  be  repeated  at  intervals 
of  from  one-half  a  minute  to  three  minutes  during  a  period  of  ten,  twenty,  or 
forty  minutes,  according  to  the  urgency  of  the  case,  the  period  of  labor,  and  the 
sensibility  of  the  patient.  In  the  succession  of  intermittent  compressions  thus 
made,  it  is  sometimes  necessary  to  act  upon  the  fundus,  sometimes  upon  the 
upper  and  lateral  portion  of  the  uterus,  never  forgetting  that  when  the  os  is  but 

1  Medical  and  Surgical  Reporter,  1877. 

2  Transactions  of  the  American  Gynecological  Society,  vol.  iv. 

3  Monat.  f.  Geburt.,  1886.  *  De  I'Expression  Uterine  appliquee  au  Foetus. 

31 


482  THE  PATHOLOGY  OF  LABOIl. 

slightly  opened,  not  readily  dilatable,  and  its  diameter  not  more  than  five  centi- 
metres, nearly  two  inches,  the  pressure  should  be  less  upon  the  fundus,  more 
upon  the  sides  of  the  uterus.  On  the  other  hand,  when  the  os  is  more  dilated 
and  yielding,  compressions  of  the  fundus  produce  the  best  effects.  In  difficult 
cases  a  longer  pause,  from  ten  to  fifteen  minutes,  should  be  made  after  ten  or 
fifteen  compressions.  Toward  the  end  of  the  labor  the  place  of  applying  pressure 
should  not  be  changed ;  it  can  scarcely  be  made  except  at  the  fundus  of  the 
uterus.  Kristeller  directs  that,  as  a  rule,  if  twenty  to  thirty  compressions 
properly  made  produce  no  result,  it  is  better  to  desist. 

Electricity,  whether  faradism  or  galvanism,  is  not  so  uniformly  effi- 
cient in  exciting  uterine  contractions,  nor  are  the  means  for  employing 
it  usually  available,  that  it  can  be  advised. 

INTERNAL  MEANS.  Medicines  may  be  administered  for  increasing 
uterine  contractions ;  the  chief  of  these  are  quinine  and  ergot.  It  is 
asserted  by  reputable  observers  that  the  former  given  in  doses  of  ten  to 
twenty  grains  has  this  effect.  Wood1  attributes  the  result  not  so  much 
to  a  specific  action  of  the  remedy  upon  the  uterus  as  by  its  arousing 
the  general  nervous  forces  of  the  system.  Klein  wachter  explains  the 
apparently  beneficial  effect  of  quinine  as  resulting  from  reduction  of 
abnormal  temperature;  after  the  fever  abates  the  pains  frequently 
increase  spontaneously,  and  succeed  each  other  rapidly,  but  not  in  con- 
sequence of  the  quinine. 

The  late  Dr.  Albert  H.  Smith  stated2  that  in  forty-two  women,  to  each  of  whom 
he  gave  fifteen  grains  of  quinine  after  actual  labor-pains  had  begun,  he  observed 
within  fifteen  minutes  a  decided  increase  in  the  frequency  and  vigor  of  the  con- 
tractions, a  rapid  progress  of  the  labor,  and,  where  there  was  no  obstruction,  a 
speedy  termination.  He  claimed  that  quinine  not  only  increased  the  activity  of 
the  normal  uterine  contractions,  but  that  it  promoted  permanent  tonic  contrac- 
tion of  the  uterus  after  the  expulsion  of  the  placenta,  that  it  lessened  the  lochial 
discharge  in  those  who  previously  had  it  in  excess,  and  that  it  also  lessened 
after-pains  in  the  majority  of  cases.  Still,  beneficial  results  from  it  are  by  no 
means  constant. 

Ergot  has  been  more  generally  given  than  any  other  agent  to  increase 
uterine  contractions.  Wernich's  investigations  show  that  it  lessens 
venous  tension,  and  while  the  blood  in  the  veins  increases,  that  in  the 
arteries  diminishes ;  anaemia  of  the  uterus  and  its  nerve-centres  occurs, 
and  hence  the  uterine  contractions  become  more  powerful  and  longer. 
According  to  Wood's  statement,3  if  ergot  be  given  in  small  doses  during 
labor,  the  natural  pains  are  simply  intensified  ;  but  if  the  dose  be  large 
enough  to  have  a  decided  effect,  their  character  is  altered  ;  they  become 
not  only  more  severe,  but  much  more  prolonged  than  normal,  and 
finally  the  intervals  of  relaxation  appear  to  be  completely  abolished 
and  the  intermittent  efforts  are  changed  into  one  violent,  continuous 
strain. 

Ergot  was  introduced  into  American  practice  in  1807,4  and  received  the  name 
o{pulvis  ad  partum;  but  as  fatal  results  at  least  to  the  child  followed  its  use,  Dr. 
Hosack  suggested  that  it  should  be  called  pulvis  ad  mortem.  Many  reputable 
obstetricians  to-day  reject  the  use  of  ergot  during  labor,  some  indeed  insisting 

1  Therapeutics,  Materia  Medica,  and  Toxicology. 

*  Transactions  of  the  College  of  Physicians  of  Philadelphia,  1875. 

3  Op.  cit.  «  Medical  Repository,  1807. 


ANOMALIES  OF  FORCE.  483 

that  it  should  be  banished  from  obstetric  practice.  It  is  believed  that  this  is  a 
mistake,  and  it  is  unjust  to  conclude  that  because  there  has  been  gross  abuse  in 
the  administration  of  the  agent— it  has  been  given  in  unsuitable  cases,  at  im- 
proper times,  or  in  too  great  quantities — it  should  therefore  not  be  used  at  all. 

Siixinger  found  good  results  from  it  in  weak  pains,  and  never  any  injurious 
effect  upon  the  child.  Schutz1  maintains  that  ergot,  in  suitable  doses,  excites 
normal  contractions. 

The  form  in  which  it  is  most  frequently  given  is  that  of  fluid  extract,  each 
minim  of  which  represents  one  grain  of  powdered  ergot.  A  preparation  called 
ergotine,  though  Squibb  denies  the  right  to  this  name,  is  also  used ;  each  grain 
of  ergotine  is  supposed  to  represent  five  minims  of  the  fluid  extract.  The  remedy 
is  given  by  the  mouth,  and  also  used  hypodermatically,  in  the  latter  case  a  watery 
solution  of  ergotine  usually  being  preferred. 

Ergot  is  not  to  be  given  in  the  first  stage  of  labor.  Exceptions  to  the 
rule  are  very  few.  Next,  it  should  not  be  given  unless  the  labor  be  so  far 
advanced,  and  the  conditions  of  presentation  and  of  the  birth-canal  are 
such  that  an  early  delivery  may  be  reasonably  expected  if  the  uterine  force 
be  made  normal.  The  most  important  rule  in  regard  to  its  administra- 
tion is  that  it  must  be  given  in  such  amount  that  the  normal  contrac- 
tions of  the  uterus  shall  be  increased ;  the  use  of  large  doses,  so  that 
continuous  action  is  excited,  may  be  followed,  and  too  often  has  been, 
by  rupture  of  the  uterus,  of  the  vagina,  or  of  the  perineum,  and  by 
the  death  of  the  child  from  asphyxia.  Ten  drops  of  the  fluid  extract, 
or  an  equivalent  quantity  of  the  infusion,  or  of  ergotine,  once  in  fifteen 
minutes,  is  a  suitable  dose  when  the  remedy  is  required  during  labor; 
if  given  for  uterine  inertia  after  labor,  the  dose  should  not  be  less  than 
a  teaspoonful.  Kleinwachter  advises  combining  Wernich's  ergotine 
with  tincture  of  cinnamon,  a  teaspoouful  of  the  latter  at  each  dose, 
stating  that  it  then  acts  more  efficiently ;  it  might  be  well,  therefore,  to 
give  ten  drops,  for  example,  of  the  fluid  extract  with  a  teaspoouful  of 
the  tincture  of  cinnamon  in  two  tablespoon fuls  of  water. 

If  after  the  rupture  of  the  membranes  and  complete  dilatation  of  the 
os  labor  does  not  advance,  instrumental  delivery  will  in  many  cases  be 
best,  both  in  the  interest  of  the  mother  and  of  the  child. 

Feeble  and  inefficient  uterine  contractions  in  the  third  stage  of  labor 
usually  have  as  their  consequence  placental  retention  and  uterine  hem- 
orrhage, and  will  hereafter  be  considered. 

Dr.  Duff,  of  Pittsburg,  advises  that  strychnia  be  given,  beginning  six  or 
eight  weeks  before  labor,  to  women  suffering  from  general  debility  and  relaxed 
muscle,  and  who  have  suffered  in  previous  deliveries  from  feeble  and  irregular 
uterine  contractions,  causing  tedious  parturition,  and,  moreover,  to  those  who 
have  had  post-partum  hemorrhage  and  failure  of  uterine  contraction  and 
retraction. 

c.  Perversion  of  uterine  force  may  be  manifested  by  continuous  gen- 
eral or  by  partial  contraction  ;  the  former  is  sometimes  called  tetanic, 
while  the  latter  causes  what  is  known  as  spastic  stricture.  Tetanic  or 
continuous  contraction  of  the  uterus  occurs  oftener  in  old  primiparse; 
it  may  be  caused  by  ergot  given  at  an  unsuitable  stage  of  labor,  or  in 
too  large  a  quantity ;  by  irritation  of  theos  from  frequent  examinations 
or  other  interference  with  the  progress  of  labor,  or  result  from  dispro- 

1  Deutsch.  Gesellschrift  t.  Gynakol.  Congress,  1890. 


484  THE  PA THOLOO  Y  OF  LA B OR. 

portion  between  the  size  of  the  foetus  and  the  pelvis,  or  from  a  mal- 
presentation,  as  of  the  shoulder,  the  uterus  struggling  to  overcome  great 
or  invincible  resistance.  The  condition  is  generally  attended  with 
severe  suffering.  This  condition,  too,  makes  difficult  or  impossible  the 
introduction  of  the  hand  into  the  uterus  for  rectifying  an  unfavorable 
presentation  or  position.  It  usually  occurs  after  the  rupture  of  the 
membranes,  and  hence  may  interfere  with  the  utero-placental  circula- 
tion or  produce  direct  pressure  upon  the  cord,  and  in  either  case  the 
child  perish  from  asphyxia ;  premature  detachment  of  the  placenta  is 
not  uncommon. 

Chloroform  given  until  deep  anaesthesia  is  produced  will  be  necessary 
in  cases  demanding  an  obstetric  practice,  e.  g.,  podalic  version  in  pre- 
sentation of  the  shoulder.  Friinkel  advises  a  hypodermatic  injection  of 
morphine  and  of  atropine  to  be  given  before  the  chloroform  inhalation  ; 
in  five  or  ten  minutes  the  uterus  relaxes,  and  the  introduction  of  the 
hand  can  be  readily  made. 

One  of  the  dangers  from  tetanic  contraction  of  the  uterus  is  rupture  ; 
and  if  this  contraction  cannot  be  abated,  Kaltenbach  advises  delivery  of 
the  child  even  by  embryotomy. 

SPASTIC  CONTRACTION.  Partial  uterine  contraction  is  usually  an 
accident  of  the  third  stage  of  labor ;  in  its  most  common  form  it  is 
known  as  hour-glass  contraction.  In  the  great  majority  at  least  of  these 
cases  the  condition  is  not  pathological ;  there  is  general  contraction  of 
the  uterine  body,  while  the  cervical  canal  remains  relaxed,  and  the 
apparent  stricture  is  the  normally  contracted  internal  os,  while  the 
placenta  remaining  in  the  uterine  cavity  prevents  the  complete  approxi- 
mation of  its  walls. 

Kleinwachter  denies  the  existence  of  partial  uterine  contractions  or  partial 
uterine  spasms,  but  asserts  that  in  consequence  of  the  relations  of  the  muscular 
fibres  to  each  other  the  uterus  must  contract  as  a  whole.  The  so-called  spas- 
modic contraction  of  the  external  os  uteri  is  nothing  more  than  a  condition  in 
which  the  upper  part  of  the  uterus  has  not  manifested  enough  power  to  over- 
come resistance ;  the  os  is  only  slightly  dilated,  and  it  presents  sharp  edges,  but 
as  soon  as  the  contractions  have  become  more  vigorous  it  opens,  and  the  so- 
called  spasm  ceases.  Again,  in  the  third  stage  of  labor,  the  placenta  may  not 
be  detached  spontaneously,  in  consequence  of  adhesions,  and  the  uterus  takes 
the  form  of  an  hour-glass  The  relaxed  lower  uterine  segment  represents  a 
funnel,  the  narrowest  portion  of  which  is  above.  The  upper  portion  of  the 
uterus  contracts  around  the  remaining  placenta,  and  immediately  below  the 
walls  of  the  body  meet,  as  nothing  intervenes ;  but  the  lower  segment  is  found, 
as  after  every  normal  birth,  in  a  condition  of  partial  paralysis — that  is,  it  is 
relaxed.  The  so-called  stricture,  therefore,  is  not  a  pathological  phenomenon, 
but  is  the  normal  condition  after  the  delivery  of  the  child.  While  this  is  the 
most  frequent  form  of  stricture,  and,  as  Kleinwachter  states,  is  not  a  pathological 
condition,  yet  the  recent  investigations  of  Bayer1  seem  to  prove  that  from  the 
anatomical  construction  of  the  uterus  strictures  may  occur  at  various  parts  of 
the  organ.  Clinical  observation,  too,  confirms  this  view,  though  the  occurrence 
of  such  cases  is  exceedingly  rare. 

But  this  ring-like  stricture  at  the  os  may  occur  in  head-last  as 
well  as  in  head-first  labor,  so  that  it  acts  as  a  cord  around  the  neck  of 
the  foetus,  preventing  in  the  one  case  the  delivery  of  the  head,  and  in 

i  Op.  cit. 


ANOMALIES  OF  THE  SOFT  PARTS.  485 

the  other  that  of  the  body.     Incision  of  the  unyielding  band  may  be 
necessary,  if  digital  dilatation  fails,  for  saving  the  child's  life. 

Kaltenbach  narrates  a  case  which  he  regards  as  of  importance  in  a  forensic 
point  of  view :  In  a  woman  twenty-four  years  old,  in  her  fourth  labor,  the  head 
of  the  child  on  the  pelvic  floor ;  delivery  with  forceps  was  necessary  from  delay, 
and  a  dead  child  extracted  with  difficulty.  The  head  and  upper  part  of  the 
throat  showed  a  deep,  bluish-red  discoloration,  at  the  middle  of  the  throat  a  fur- 
row ;  there  was  no  coil  of  the  cord  about  the  neck.  Such  a  condition  might  have 
been  mistaken,  under  other  circumstances,  as  proving  infanticide  from  strangu- 
lation. 

GREAT  PAIN.  Excessive  suffering  in  labor  may  be  caused  by  very 
great  distention  of  the  uterus,  by  peritoneal  inflammation,  by  mal- 
presentation  or  great  size  of  the  foatus,  or  it  may  arise  from  a  general 
hypereesthetic  condition.  It  does  not  interfere  with  the  action  of  the 
uterus,  but  it  does  prevent  the  assisting  action  of  the  abdominal  mus- 
cles in  the  second  stage  of  labor. 

In  the  treatment  of  excessive  pain,  of  course,  the  cause  must  be 
ascertained,  and,  if  possible,  removed  ;  but  in  many  cases  remedies  must 
be  given  directly  for  the  suffering  ;  thus  we  may  use  chloral  or  lauda- 
num by  rectal  injection,  or  morphine  hypodermatically,  or  anaesthetic 
inhalation. 

ANOMALIES  OF  THE  SOFT  PARTS.  These  will  include  not  only 
anomalies  of  the  uterus  as  to  development  and  position,  as  to  the  con- 
dition of  the  os  and  the  cervix,  and  as  to  neoplasms,  but  also  certain 
deviations  of  adjacent  organs  from  the  normal. 

ANOMALIES  OF  FORM  AND  OF  POSITION  OF  THE  UTERUS.  The 
arrest  of  pregnancy  in  a  rudimentary  horn  of  the  uterus  has  been  stated 
in  connection  with  the  subject  of  ectopic  development  of  the  ovum.  But 
in  the  cases  in  which  the  pregnancy  has  occurred  in  the  fully  developed 
horn,  either  of  a  uterus  unicornis  or  bicornis,  its  course  has  been  unin- 
terrupted and  the  labor  normal ;  nevertheless,  in  some  instances  of  the 
latter  malformation  it  is  stated  that  the  unimpregnated  horn  has  inter- 
fered with  the  entrance  of  the  foetus  into  the  vagina,  and  that  there  is  a 
greater  liability  to  a  transverse  position  of  the  foatus.  Instances  have 
occurred  in  which  both  horns  were  pregnant,  the  labor  taking  place  in 
each  at  or  near  the  same  time ;  in  other  cases  there  has  been  an  abortion 
from  one  horn,  while  the  pregnancy  in  the  other  was  completed. 

Cruveilhier  has  mentioned  a  curious  instance  of  double  uterus  with  duplicity 
of  the  vagina  also,  the  woman  being  pregnant ;  she  was  visited  by  one  physician 
who  asserted  that  she  was  not  pregnant,  and  then  by  another  who  found  her  in 
labor ;  the  difference  of  opinion  arose  from  the  fact  that  one  practitioner  made 
a  digital  examination  through  the  vagina,  which  communicated  with  the  non- 
pregnant  half  of  the  womb,  while  the  second,  making  his  through  the  other 
vagina,  recognized  the  dilatation  of  the  os  and  the  presenting  part  of  the  foetus. 

Latero-positions  of  the  uterus,  though  usually  rectified  by  uterine 
and  abdominal  contractions  bringing  the  uterine  in  correspondence  with 
the  pelvic  axis,  can  easily  be  corrected,  if  necessary,  by  having  the 
patient  lie  upon  the  side  opposite  to  that  of  the  displacement.  Ante- 
version  or  anteflexion  is  remedied  simply  by  the  dorsal  position  or  by 


486  THE  PATHOLOGY  OF  LABOR. 

the  abdominal  bandage ;  Dr.  Barker1  stated  that  in  some  cases  of  pendu- 
lous abdomen  he  has  been  obliged  to  place  the  patient  in  the  dorsal 
position,  her  head  and  shoulders  being  considerably  lower  than  her  hips. 

Prolapse  of  the  uterus  can  only  occur  in  case  of  a  very  large  pelvis  ;  very 
rarely  the  head  passes  out  still  inclosed  in  the  lower  uterine  segment. 

OCCLUSION  AND  NARROWING  OF  THE  Os  UTERI.  Conglutination 
of  the  external  orifice  is  occasionally  met  with.  The  labor  is  tedious, 
the  lower  uterine  segment  greatly  thinned,  and  upon  digital  examination 
no  os  can  be  felt,  but  usually  a  slight  pit  or  depression  marks  its  place, 
though  sometimes  this  may  fail ;  the  closure  in  most  cases  is  simply 
from  a  thickened  secretion,  but  may  be  consequent  upon  a  superficial 
endometritis.  During  a  contraction  of  the  uterus  pressure  should  be 
made  with  the  point  of  the  finger  or  with  the  uterine  sound  at  the 
depressed  place,  or  if  this  be  absent,  at  that  which  is  most  thinned,  and 
the  os  wTill  open ;  it  may  be  widened  simply  by  the  finger,  or,  as  in  a 
case2  reported  by  the  late  Dr.  Albert  H.  Smith,  by  means  of  a  uterine 
dilator. 

In  rare  cases  it  happens  that  the  union  between  the  maternal  and  foetal  mem- 
branes in  the  immediate  vicinity  of  the  external  orifice  is  so  firm  that  the  lower 
segment  of  the  uterus  cannot  retract  over  the  ovum.  Should  this  be  the  case, 
detachment  of  the  membranes  or  rupture  of  the  sac  is  indicated. 

Cicatricial  closure  of  the  os  may  have  resulted  from  an  inflammation  following 
a  previous  labor,  or  from  the  application  of  powerful  caustics  to  the  cervix.  It 
is  rarely  complete,  and  if  there  be  atresia,  of  course,  it  must  have  originated 
subsequently  to  impregnation. 

Undoubtedly,  in  some  of  the  cases  in  which  atresia  of  the  os  was  diagnosed 
there  had  been  only  stenosis.  Failing  with  the  finger  to  discover  the  os,  the  next 
step  will  be  to  expose,  by  means  of  a  speculum,  the  parts,  and  then  there  will 
usually  be  seen  at  the  os  a  little  mucus  projecting,  or,  if  the  membranes  have 
ruptured,  and  especially  during  a  uterine  contraction,  there  will  be  discovered 
a  small  stream  of  water  escaping. 

Of  course,  if  it  be  a  simple  stenosis,  or  conglutination,  pressure  with  the  knob  of 
a  uterine  sound  will  open  it  so  that  dilators  or  the  finger  may  be  used.  But  if 
atresia  is  present  an  incision  is  necessary ;  Winckel  advises  a  superficial  crucial 
incision ;  antisepsis  must  be  carefully  observed.  In  a  case  of  this  kind,  seen  two 
years  ago  with  Dr.  Markley,  of  Hatboro,Pa.,  neither  he  nor  I  could  discover  the 
os,  and  I  made  with  scissors  a  cut  through  the  thin  tissue  where  I  believed  the 
os  ought  to  have  been;  this  opening  readily  dilated,  and  the  labor  was  ended  by 
forceps. 

RIGIDITY  OF  THE  Os.  Under  the  different  names  of  anatomical, 
simple,  or  mechanical  rigidity  of  the  os,  a  condition  is  met  with,  espe- 
cially in  old  primiparse,  which  causes  great  delay,  and  in  rare  cases 
presents  an  invincible  obstacle  to  labor.  The  cervix  has  not  been  com- 
pletely effaced,  and  the  borders  of  the  os  are  thick,  resistant,  hard,  but 
not  sensitive.  In  some  instances  the  neck  is  hypertrophied,  and  in 
these  it  is  not  unusual  to  find,  after  labor  has  continued  for  some  time, 
a  thrombus  involving  the  anterior  or  posterior  lip.  At  first  warm 
baths,  warm  vaginal  douches,  and  a  laudanum  injection  into  the  rectum 
may  be  tried,  then  artificial  dilatation  ;  Schroder  advises  incisions  freely 
made  by  curved  scissors  or  by  a  probe-pointed  bistoury. 

1  Transactions  of  the  American  Gynecological  Society,  vol.  v.  p.  274. 
»  Medical  and  Surgical  Reporter,  1877. 


ANOMALIES  OF  THE  SOFT  PAIITS. 


487 


Remarkable  results  have  been  recorded  by  Farrar1  as  resulting  from 
the  application  of  a  10  per  cent,  solution  of  cocaine  to  a  rigid  os  ;  it  is 
probable  that  Dr.  Farrar  has  made  a  most  valuable  addition  to  the 
means  for  treating  this  condition. 

Dr.  Robert  Barnes,  from  whose  work  the  subjoined  illustration  is  taken,  nar- 
rates a  case  in  which  the  labor  was  impeded  by  a  hypertrophied  cervix :  "  A 
primipara,  aged  twenty-two,  was  in  labor.  The  cervix  protruded  through  the 
vulva  about  three  inches,  forming  a  mass  equal  to  a  man's  wrist  in  circumference. 
After  reducing  the  cervix  in  the  vagina  the  head  could  be  felt.  The  cervix  had 
a  hard,  gristly  feel.  Free  incisions  in  the  os  externum  were  made,  so  that  the 
os  externum  was  freely  opened  up  to  meet  the  natural  expansion  of  the  os 
internum.  She  was  then  delivered  after  an  anxious  labor  of  fifty-two  hours." 

FIG.  184. 


ILLUSTRATING  LABOR  WITH  HYPERTROPHIC  ELONGATION  OF  THE  CERVIX. 

NEOPLASMS  OF  THE  UTERUS.  The  injurious  influence  of  uterine 
fibroids  upon  labor  depends  upon  their  size  and  their  position.  If  the 
tumors  are  small,  or  subperitoneal,  they  may  present  no  complication, 
and,  indeed,  may  not  be  recognized  in  some  cases  until  the  labor  is  over. 

1  Transactions  of  the  London  Obstetrical  Society  for  1894. 


488  THE  PATHOLOGY  OF  LABOR. 

Tumors  of  the  neck,  when  large,  prevent  the  presenting  part  from 
entering  the  pelvis  ;  interstitial  tumors  of  the  body  may  be  the  cause 
of  rupture  of  the  uterus,  or  of  post-pa rtum  hemorrhage,  especially  if  the 
placenta  be  attached  to  the  part  of  the  uterine  wall  which  they  occupy. 
The  relative  proportion  of  fibroids  of  the  neck  to  those  of  the  body  is 
much  greater  in  pregnant  than  in  non-pregnant  women.  Thus,  while 
there  are  twenty  cases  in  which  these  tumors  are  situated  in  the  body 
to  one  where  such  a  growth  occupies  the  neck  of  the  uterus  in  the  non- 
pregnant,  the  proportion  is  only  five  to  one  in  the  pregnant,  as  ascer- 
tained by  Chahbazian  from  the  study  of  310  cases  of  uterine  fibroids 
complicating  pregnancy.1 

Chadwick2  has  reported  ten  cases  of  pregnancy  and  labor  complicated 
with  fibroids,  with  the  following  results :  1  miscarriage,  7  recoveries 
of  mother  and  7  living  children,  2  deaths  of  mothers  and  2  stillborn 
children.  Fortunately  in  one-half  of  cervical  fibroids  observed  in  preg- 
nancy or  labor  the  tumors  are  pedunculated,  38  out  of  76,  according  to 
Chahbazian's  statistics.  Another  notable  fact  is  that  transverse  and 
pelvic  presentations  are  greatly  increased,  so  that  the  two  nearly  equal 
the  number  of  vertex  presentations.  In  Chadwick's  cases  there  were 
in  9  labors  7  head  presentations  and  2  transverse. 

In  the  treatment  of  fibrous  tumors  of  the  uterus  complicating  labor, 
Lefour  advises  at  first  to  wait,  letting  Nature  accomplish  all  she  can, 
but  this  delay  must  be  determined  by  the  interest  of  the  mother  and 
child.  Next,  act  upon  the  tumor  by  its  removal,  or  by  pushing  it  up 
from  the  pelvis.  Extirpation  of  the  tumor  was  first  performed  by 
Michellacci  in  1791.3  The  operation  has  been  repeatedly  done  since, 
and  with  almost  unvarying  success  as  far  as  the  mother  is  concerned, 
but  with  a  very  large  foetal  mortality.  As  in  a  large  proportion  of 
cases  the  tumor  is  cervical,  and  as  in  one-half  of  these  it  is  pedunculated 
(see  Fig.  185),  its  removal  will,  under  such  circumstances,  usually  be 
neither  difficult  nor  dangerous.  If  the  tumor  has  no  pedicle,  it  must 
be  enucleated.  But  other  tumors  may  occupy  such  a  position  that  they 
cannot  be  removed,  as,  for  example,  a  subperitoneal  growth  with  a  long 
pedicle  that  has  dropped  into  the  pelvis,  or  a  tumor  involving  the  neck 
and  the  lower  part  of  the  body  of  the  uterus.  Here  an  effort  must  be 
made  to  push  it  above  the  pelvic  inlet.  The  patient  is  put  in  the  knee- 
chest  position,  and  the  fingers  or  the  entire  hand  introduced  into  the 
vagina  and  used  to  press  the  tumor  out  of  the  way  ;  of  course,  pressure 
is  made  only  in  the  intervals  between  contractions.  If  it  is  impos- 
sible either  to  extirpate  the  growth  or  to  remove  it  from  the  pelvis, 
and  space  permit,  the  forceps  or  podalic  version  may  be  tried.  The 
results  from  the  former  are  very  much  more  favorable  than  those  given 
by  version,  and  therefore  it  is  to  be  preferred.  In  absolute  narrowing 
of  the  pelvic  cavity,  Cffisarean  section  is  indicated ;  the  supra-vaginal 
amputation  of  the  uterus,  Porro's  operation,  may  be  done.  If  abdom- 
inal section  is  forbidden,  embryotomy  is  the  only  resort;  but  while,  of 
course,  all  the  children  are  lost,  it  gives  a  fearful  mortality  for  the 

1  Des  Fibromes  du  Col  de  1'Uterus  au  point  de  vue  de  la  Grossesse  et  de  1'Accouchement. 

2  Boston  Medical  and  Surgical  Journal,  July  30,  1885. 

3  See  Chahbazian,  op.  cit. 


ANOMALIES  OF  THE  SOFT  PARTS. 


489 


mothers,  66  per  cent,  of  them  perishing.  No  one  can  hesitate,  if  the 
child  is  dead,  in  performing  embryotomy,  provided  the  mother  does  not 
run  a  greater  risk  than  from  abdominal  section. 


FIG.  185. 


A  POLYPUS  OCCUPYING  THE  PELVIC  CAVITY  IN  LABOR.    (From  RAMSBOTHAM.) 

Cancer  of  the  uterus  gives  a  very  unfavorable  prognosis  ;  Cohustein 
found  that  of  126  mothers  only  54  survived,  while  72  died  during 
labor  or  in  the  puerperal  period.  If  the  disease  partially  affects  only 
the  lips  of  the  uterus,  labor  may  go  on  without  special  difficulties,  and 
there  may  be  no  great  hemorrhage.  But  if  the  entire  cervix  be  affected, 
and  especially  if  the  disease  has  extended  to  the  adjoining  part  of  the 
body  of  the  uterus,  it  is  impossible  for  the  diseased  tissue  to  dilate,  and 
the  expulsion  of  the  foetus  can  only  occur  after  rupture  of  the  unyielding 
ring,  which  causes  such  a  serious  hemorrhage  that  may  be  difficult  or 
impossible  to  arrest.  Incisions  of  the  cervix  thus  degenerated  are 
dangerous  because  of  consequent  hemorrhage,  and,  according  to  Klein- 
wachter,  because  they  must  be  carried  through  the  entire  wall  and  thus 
injure  the  peritoneum  ;  nevertheless,  Charpentier  advises  them,  and 
directs  that  they  be  followed  by  the  application  of  the  forceps.  Her- 
mann1 states  that  "  when  labor  has  actually  come  on,  expansion  of  the 

1  London  Obstetrical  Society's  Transactions,  vol.  xx. 


490 


THE  PATHOLOGY  OF  LABOR. 


os  uteri  should  bo  aided  by  making  numerous  small  incisions  in  its  cir- 
cumference." He  also  says  that  when  dilatation  is  in  progress,  if  it  is 
necessary  to  accelerate  labor  the  forceps  is  preferable  to  version.  When 
the  disease,  however,  involves  the  entire  cervix,  the  timely  performance 
of  the  Csesarean  operation  is  generally  considered  as  indicated,  both  in 
the  interest  of  the  mother  and  of  the  child. 

Winckel,  considering  the  large  mortality  of  the  Csesarean  operation  in  cancer 
of  the  uterus,  and  the  great  uncertainty  of  the  child  living,  prefers  perforation 
and  extraction  of  the  lessened  foetus  through  the  vagina,  thus  securing  to  the 
mother,  it  may  be,  several  months  of  life.  He  takes  the  ground  that  delivery  of 
the  lessened  child  is  more  humane.  Certainly  "Winckel's  advice  deserves  very 
serious  consideration,  though  in  this  he  is  not  in  accordance  with  the  majority 
of  authorities. 

Abdominal  extirpation  of  the  uterus  in  labor  has  been  employed  in  a  few 
cases,  but  the  fatality  of  the  operation  is  great.  Vaginal  removal  a  few  weeks 
after  labor  has  given  good  results,  for  the  time  at  least. 

ANOMALIES  OF  ADJACENT  ORGANS.  Chief  among  these  which  may 
interfere  with  labor  are  tumors  of  the  ovary,  the  danger  or  difficulty 

FIG.  186. 


AN  ENLARGED  OVARY  BLOCKING  UP  THE  PELVIC  CAVITY  IN  LABOR.    (From  RAMSBOTHAM.) 

depending  upon  their  size.,  position,  mobility,  and  nature.  Thus,  an 
immobile,  solid  tumor  in  the  pelvis  is  more  serious  than  a  fluid  cystic 
tumor.  Even  if  the  turner  furnished  no  obstacle  to  the  birth,  there  may 


ANOMALIES  OF  THE  SOFT  PARTS. 


491 


be,  as  Kleiuwachter  states,  twisting  of  the  pedicle  during  labor,  and 
this  be  followed  by  rupture  of  the  cyst  in  childbed,  with  fatal  peritonitis. 
Dermoid  cysts  give  a  more  unfavorable  prognosis  than  those  which  are 
liquid,  because  they  are  fixed  and  their  contents  solid,  so  that  they  as 
a  rule  cannot  be  pushed  out  of  the  way  nor  their  size  lessened  by 
puncture.  Fibroid  tumors  of  the  ovary,  especially  if  calcareous  change 
has  occurred,  may  cause  great  difficulty  by  descending  into  the  pelvis  in 
advance  of  the  presenting  part  of  the  foetus,  and  thus  preventing  its 
progress ;  on  account  of  their  hardness,  it  is  very  difficult  when  they 
have  thus  become  fixed  to  distinguish  them  from  pelvic  exostoses.1 

In  disturbances  of  labor  caused  by  ovarian  tumors,  reposition  is  the 
first  thing;  if  this  fails,  puncture,  usually  by  the  vagina;  if  this  is 
impossible,  the  Csesarean  operation. 

EECTOCELE  AND  CYSTOCELE.  Obstruction  of  the  vagina  from  pro- 
jection of  the  rectum  loaded  with  feces,  or  of  the  bladder  filled  with 


FIG.  187. 


CYSTOCELE  COMPLICATING  LABOR. 


urine,  can  scarcely  offer  a  serious  hindrance  to  childbirth,  especially  if 
the  obstetrician  gives  heed  early  in  the  labor  to  having  each  of  these 
organs  thoroughly  evacuated.  Ramsbotham,  however,  has  stated  that 
he  has  seen  many  instances  of  the  bladder  prolapsing  before  the  head, 


Kleinwachter,  op.  cit. 


492  THE  PATHOLOGY  OF  LABOR. 

and  mentions  two  cases  in  which  it  was  punctured,  one  practitioner 
mistaking  it  for  a  dropsical  head,  and  the  other  for  the  bag  of  waters. 
Such  errors  can  only  result  from  culpable  ignorance  or  carelessness. 

Dr.  Busey1  is  the  author  of  a  paper  upon  cystocolpocele  complicating  preg- 
nancy and  labor ;  by  cystocolpocele  is  meant  prolapse  of  the  bladder  into  the 
vaginal  passage;  and  if  the  sac  occupies  the  cavity  of  the  pelvis,  filling  the  hol- 
low of  the  sacrum,  pushing  the  os  uteri  beyond  reach,  and  occluding  the  vaginal 
passage,  it  is  complete.  One  of  the  most  marked  results  of  this  displacement  of 
the  bladder  is  lingering  labor.  The  diagnosis  is  made  by  introducing  the  catheter 
into  the  bladder  and  evacuating  it.  This  displacement  of  the  bladder  in  relation 
to  pregnancy  and  labor  was  very  fully  considered  by  Broadbent,  in  1863,  in  a 
paper  read  before  the  London  Obstetrical  Society.  In  referring  to  the  diagnosis 
he  states:  "The  prolapsed  condition  of  the  bladder  is  readily  recognized  on 
examination,  especially  when  it  contains  urine  in  any  considerable  quantity. 
The  cavity  of  the  pelvis  is  found  to  be  occupied  by  a  bag  of  fluid,  easily  dis- 
tinguished from  the  ftctal  membranes  by  the  fact  that  it  springs  from  the  pubis, 
and  does  not  permit  the  finger  to  pass  between  it  and  the  symphysis.  As  this 
sac,  the  bladder,  fills  up  the  hollow  of  the  sacrum,  the  os  uteri  cannot  be  reached 
until  the  urine  is  evacuated ;  and  if  this  is  done  by  the  catheter,  the  instrument 
can  be  felt  from  the  vagina  and  followed  to  every  part  of  the  bladder.  When 
the  bladder  is  perfectly  empty  the  displacement  may  be  overlooked,  but  the 
finger,  instead  of  circumscribing  the  lower  segment  of  the  uterus  readily,  meets 
anteriorly  with  the  bladder,  passing  from  the  symphysis  pubis  to  the  uterus,  and 
usually  disposed  in  ruga? ;  the  introduction  of  the  catheter  at  once  makes  the 
case  clear." 

Whether  called  cystocele,  prolapse  of  the  bladder,  or  cystocolpocele, 
the  obvious  indication  is  to  empty  the  organ  and  press  it  out  of  the 
way  of  the  descent  of  the  presenting  part  of  the  foetus. 

Vesical  calculi  have  in  very  rare  cases  obstructed  the  birth-passage. 
It  will  generally  be  easy  to  push  a  tumor  thus  formed  up  out  of  the 
pelvis ;  if  not,  an  opening  may  be  made  into  the  bladder  from  the 
vagina,  and  the  stone  or  stones  removed,  after  which  sutures  are  to  be 
introduced  as  in  the  operation  for  vesico- vaginal  fistula. 

The  vagina  may  present  an  obstacle  to  labor  from  congenital  or 
acquired  circular  stenosis,  the  former  being  very  rare,  or  from  cicatricial 
bands.  Patient  artificial  dilatation,  dividing  bands  with  blunt-ended 
scissors  or  probe-pointed  bistoury,  will  generally  prove  sufficient  to 
secure  delivery. 

In  rare  cases  a  resisting  hymen  may  be  an  obstruction  ;  of  course, 
incisions  remove  the  resistance. 

Still  rarer  are  the  cases  in  which  vaginismus  prevents  delivery  ;  Beu- 
neke  saw  such  a  case,  in  which  even  craniotomy  was  necessary  (Kalten- 
bach);  usually  the  difficulty  is  overcome  by  deep  anesthesia. 

1  Transactions  of  the  American  Gynecological  Society,  vol.  xii. 


CHAPTER    VII. 

ANOMALIES    OF    THE    PELVIS. 

ANOMALIES  of  the  pelvis  may  be  conveniently  divided  into  those  of 
position,  of  size,  and  of  form. 

The  first  division  includes  two  varieties.  The  pelvis  has  a  normal 
inclination  or  obliquity,  and  the  deviations  from  this  obliquity  may  be 
by  excess  or  by  defect ;  that  is,  the  inclination  may  be  increased  or 
lessened. 

So,  too,  the  second  division  includes  two  classes  :  1,  that  in  which 
the  pelvis  undergoes  uniform  increase,  pelvis  cequabiliier  justo-major ; 
and,  2,  that  in  which  similar  decrease  occurs,  pelvis  cequabiliier  justo- 
minor.  The  latter  is  described  as  a  pelvis  uniformly  contracted ;  in 
order  that  a  pelvis  may  be  called  contracted  the  true  conjugate  must  be 
lessened  one  centimetre  and  a  quarter,  but  if  there  be  a  uniform  lessen- 
ing of  all  the  diameters  one  centimetre,  or  about  four-tenths  of  an  inch, 
then  general  contraction  is  said  to  be  present. 

The  third  division  includes  those  characterized  by  change  in  the 
pelvic  form ;  in  the  second  class  there  are  simply  changes  in  size,  the 
pelvis  remaining  symmetrical,  but  in  this  it  becomes  asymmetrical — its 
form  perverted,  or  the  pelvis  is  said  to  be  deformed,  and,  so  far  as  the 
injurious  resu/ts  in  relation  to  labor  are  concerned,  vitiated.  Such 
deviations  from  the  normal  may  involve  the  vertical  diameters  with 
reference  to  the  transverse,  or  the  latter  with  regard  to  each  other,  and 
these  constitute  the  chief  ones  to  be  considered.  The  last  presents  three 
classes:  1,  that  in  which  the  antero-posterior  diameter  is  lessened;  2, 
the  transverse  diameter  is  lessened ;  and,  3,  the  diminution  is  in  the 
oblique  diameter. 

These  various  pelvic  anomalies  will  now  be  considered  in  the  order 
that  has  been  given. 

1.  Anomalies  of  Position.  As  already  stated,  deviations  from  the 
normal  obliquity  of  the  pelvis  are  two ;  this  obliquity  may  be  increased 
or  lessened. 

Lobstein,1  in  an  unpublished  memoir  presented  to  the  Society  of  Medicine  of 
the  Faculty  of  Paris,  1817,  first  directed  the  attention  of  obstetricians  to  the 
consequences  of  too  great  or  too  slight  inclination  of  the  pelvis.  The  anterior 
obliquity  may  be  so  exaggerated  that  the  axis  of  the  inlet  is  horizontal.  Moreau 
narrates  a  case  in  which  the  plane  of  the  inlet  was  vertical,  and  there  was  also 
associated  with  this  vicious  inclination  of  the  pelvis  narrowing  from  rickets, 
which  compelled  the  Csesarean  operation.  Naegele  has  described  the  case  of  a 
married  woman  in  whom  the  inferior  strait  was  turned  directly  behind ;  the 
pubic  symphysis  and  the  upper  part  of  the  sacrum  were  directed  horizontally, 
and  consequently  the  plane  of  the  superior  strait  was  vertical ;  the  venereal  act 
never  took  place  but  in  a  position  opposite  to  the  natural  one.  She  became 

1  Dictionnaire  Encyclopedique  des  Sciences  medicates,  t.  viii. 


494  THE  PATHOLOGY  OF  LABOR. 

pregnant,  but  the  pelvis  being  normal  no  difficulty  occurred  at  labor;  six  other 
consecutive  pregnancies  occurred,  and  ended  with  the  same  facility  as  the  first. 

By  so-called  posterior  obliquity — a  true  obliquity  in  a  backward  direction  of 
course  is  impossible— is  generally  understood  a  marked  lessening  of  the  normal 
obliquity,  that  may  go  to  such  extreme  that  the  plane  of  the  inlet  becomes  hori- 
zontal. This  obliquity  is  usually  associated  with  deformed  pelvis,  but  it  has  been 
observed  independently  of  such  vitiation. 

In  cases  of  posterior  obliquity  or  pelvic  retroversion  "  the  vulva  is  directed 
much  more  in  front  than  usual,  and  the  pubic  syinphysis  presents  a  direction 
more  or  less  approaching  the  vertical.  The  superior  half  of  the  sacrum  has 
become  parallel  to  the  axis  of  the  trunk,  and  the  lumbar  region  is  more  or  less 
without  its  posterior  concavity— a  flat  back.  Finally,  the  point  of  the  coccyx  is 
always  found  in  the  vertical  position  either  at  the  level  or  beneath  the  summit 
of  the  pubic  arch,  and  the  last  false  rib  is  generally  nearer  the  iliac  crest  than  in 
the  normal  state." 

In  addition  to  these  obliquities,  Lenoir  has  given  a  description  of 
lateral  obliquity  of  the  pelvis.  According  to  Depaul,  lateral  obliquities 
are  very  frequently  found  in  connection  with  rhachitic  skeletons,  and 
even  in  cases  of  shortening,  atrophy,  or  old  luxations  of  the  abdominal 
members. 

Naegele,  in  referring  to  inclination  of  the  pelvis,  makes  the  following  remarks  : 
"  Even  when  this  inclination  is  normal,  it  quite  often  happens  in  cephalic  pre- 
sentation that  the  head  presses  upon  the  superior  border  of  the  pubic  symphysis, 
and  thus  to  some  degree  its  entrance  into  the  pelvic  cavity  is  retarded.  If  in 
such  cases  the  other  conditions  of  the  mechanism  of  labor  are  normal,  this  re- 
sistance is  overcome  soon  by  the  efforts  of  nature,  and  delivery  is  accomplished 
without  special  difficulty.  But  if  at  the  same  time  there  is  a  more  or  less  great 
disproportion  between  the  head  and  the  basin,  the  resistance  presented  by  the 
anterior  wall  of  the  latter  exerts  a  very  injurious  influence.  This  influence  is 
much  worse  still  when  at  the  same  time  the  inclination  of  the  pelvis  is  too  great. 
If,  as  frequently  happens,  an  inclination  exceptionally  great  coincides  with  nar- 
rowing of  the  pelvis,  obstetric  operations  may  be  rendered  much  more  difficult. 
For  this  reason  it  appears  necessary  in  all  cases  where  the  head  of  the  foetus 
strikes  against  the  pubic  symphysis  at  entering  the  pelvis  to  have  the  woman  lie 
in  such  a  way  that  the  lumbar  vertebrae  may  be  strongly  flexed ;  that  is  to  say, 
give  her  a  half-sitting  posture  by  raising  the  hips  and  the  upper  part  of  the 
trunk,  or  have  her  lie  upon  the  side,  her  back  bent  forward,  and  the  thighs 
strongly  flexed  upon  the  pelvis." 

2.  Anomalies  of  Size.  This  division,  which  includes  uniform  increase 
and  uniform  lessening  of  the  size  of  the  pelvis,  might  also  be  distin- 
guished as  symmetrical  anomalies  in  contradistinction  to  the  third  class, 
in  which  the  anomalies  are  chiefly  asymmetric. 

The  illustration,  Fig.  188,  taken  from  Depaul,  represents  the  justo- 
major  and  the  justo-minor  pelvis,  while  the  line  marked  B  is  the  measure 
of  the  distance  between  the  iliac  crests  in  a  normal  pelvis. 

a.  The  justo-major  pelvis.  In  the  pelvis  marked  A  the  distance  be- 
tween the  antero-superior  spinous  processes  was  28  centimetres,  more 
than  11  inches,  and  that  between  the  iliac  crests  32  centimetres,  more 
than  12  inches.  The  antero-posterior  diameter  of  the  inlet  was  13  cen- 
timetres (5  inches),  the  transverse  16  centimetres  (6.3  inches),  and  the 
oblique  15  centimetres  (5.9  inches).  The  justo-major  pelvis  has  been 
justly  compared  to  the  pelvis  of  a  giantess  found  in  a  woman  of  ordi- 
nary size. 

Schroder  taught  that  the  generally  enlarged  pelvis  did  not  disturb 


ANOMALIES  OF  THE  PELVIS. 


495 


the  course  of  labor,  causing  this  to  be  rapid,  and,  in  short,  that  it 
should  not  be  regarded  as  pathological  unless  the  same  conditions  were 
present,  as  might  be  observed  in  the  case  of  a  normal  pelvis.  On  the 
other  hand,  most  obstetricians  believe  that  such  a  pelvis  contributes  to 
precipitate  birth  by  the  ampler  bony  canal  through  which  the  foetus  is 
transmitted. 

b.  The  pelvis  junto-minor,  or  the  generally-contracted  pelvis.  This 
pelvis,  as  has  been  before  stated,  is  characterized  by  a  uniform  lessening 
of  its  diameters  ;  it  is  one  of  the  most  important  anomalies  of  the  pelvis. 


A.  Justo-major  pelvis.    B.  Normal  distance  between  the  iliac  crests.    C.  Justo- minor  pelvis. 

At  least  three  varieties  of  this  pelvis  have  been  described.  In  the  first 
the  pelvis  has  the  form  characteristic  of  the  sex,  but  seems  to  have  been 
arrested  in  its  development ;  the  bones  are  frailer  and  smaller,  and, 
though  it  is  usually  found  in  women  whose  stature  is  under  the  normal, 
it  may  also  sometimes  belong  to  tall  women  who  are  with  this  exception 
perfectly  developed.  While  in  another  variety  to  be  mentioned,  there 
usually  is  a  departure  from  the  strict  definition  of  the  justo-minor 
pelvis — uniform  lessening  of  the  pelvic  measurements — this  corresponds 


496  THE  PATHOLOGY  OF  LABOR. 

quite  accurately.  The  second  variety,  the  dwarf's  pelvis,  presents  the 
usual  characteristics  of  the  normal  female  pelvis,  only  it  is  under  size; 
there  is  a  correspondence  between  the  pelvis  and  the  height,  and  the 
bones  of  the  former  correspond  in  their  development  as  to  size  and 
firmness  with  those  of  the  rest  of  the  skeleton.  The  third  variety  is 
the  masculine  pelvis.  This  may  have  the  external  form  of  the  female 
pelvis,  but  in  some  very  strongly  resembles  the  male.  The  bones  are 
thick  and  strong ;  the  sacrum  is  narrow ;  the  ilia  are  straighter  than 
normal ;  and  the  ischia  are  nearer  each  other.  The  external  measure- 
ments may  vary  but  slightly  from  the  normal,  and  the  contraction  may 
not  be  uniform,  but  may  concern  the  inlet,  the  cavity,  or  the  outlet ;  in 
the  latter  case  the  pelvis  becomes  funnel-shaped. 

The  equally-contracted  pelvis  is  not  frequently  seen;  of  its  three 
varieties  the  masculine  basin  is  the  least,  the  dwarf's  the  most  rare. 

The  causes  of  the  justo-minor  pelvis  are  generally  obscure.  In  some  instances 
the  anomaly  may  result  from  rickets.  This  origin  has  been  generally  accepted. 
Zweifel  states  that  he  has  seen  one  typical  instance  of  generally  equally  con- 
tracted pelvis  which  was  caused  by  rickets,  though  this  disease  usually  produces 
another  abnormal  form.  Muller  has  mentioned  the  frequency  of  this  pelvis  in 
crelins  and  semicretins.  Still,  there  remain  the  great  majority  of  cases  of  this 
partial  pelvic  development  which  cannot  be  attributed  to  any  constitutional 
disease  either  hereditary  or  acquired. 

Before  giving  the  diagnosis  of  the  generally-contracted  pelvis,  study- 
ing the  mechanism  of  labor  in  such  pelves,  and  the  treatment  of  labor 
there  occurring,  it  is  necessary  first  to  consider  the  means  by  which 
deformities  of  the  pelvis  are  known — a  subject  the  importance  of  which 
cannot  be  exaggerated. 

Kleinwachter  observes,  no  error  in  diagnosis  is  so  terribly  avenged 
upon  the  mother  and  the  child  as  one  relating  to  contracted  pelvis. 

It  might  be  added  that  the  vengeance  falls,  too,  upon  the  obstetrician,  for  he 
can  never  escape  self-reproach  if,  suitable  opportunity  having  been  his,  he  has 
failed  to  recognize  the  deformity  in  time  to  ward  off  at  least  some  of  its  conse- 
quences, or  possibly  saving  both  mother  and  child  by  means  appropriate  to  the 
emergency.  A  primigravida,  for  example,  is  in  labor  at  the  normal  end  of 
pregnancy ;  her  form  is  apparently  perfect,  her  health  excellent,  and  there  is 
not  the  least  suspicion  that  the  pelvis  is  abnormal.  The  first  period  of  labor  is 
somewhat  longer  than  usual ;  the  second  is  protracted  until  instrumental  inter- 
ference is  demanded  in  her  interest,  if  not  in  that  of  the  child.  One  or  more 
consultants  come,  and  the  forceps  is  tried,  first  one  pattern,  and  then  another, 
but  all  in  vain,  Meantime,  serious  inroads  upon  the  patient's  strength  have 
been  made,  and  disappointment  at  the  delay  in  delivery  almost  brings  her  to 
despair.  The  next  step  is  a  craniotomy,  the  attendants  now  fully  convinced  that 
it  is  impossible  for  a  living  child  to  pass  through  the  narrowed  inlet.  But  before 
craniotomy  and  extraction  of  the  mutilated  foetus  can  be  completed  she  dies. 
Examination  of  the  pelvis  after  death  proves  that  the  antero-posterior  diameter 
of  the  inlet  is  barely  two  inches  and  a  half.  A  timely  Csesarean  operation  would 
probably  have  saved  both  mother  and  child,  or,  this  being  refused,  the  mother's 
salvation  might  have  been  secured  if  the  embryotomy  had  not  been  deferred  until 
she  was  exhausted. 

DIAGNOSIS  OF  PELVIC  ANOMALIES.  This  is  made  by  the  recog- 
nition and  appreciation  of  signs  which  may  be  classified  as  probable  and 
certain.  The  former  are  ascertained  from  the  history  of  the  patient, 
from  her  general  appearance,  carriage,  walk,  stature,  etc.,  while  the 


ANOMALIES  OF  THE  PELVIS.  497 

latter  are  sought  by  direct  examination  of  the  pelvis.  In  the  history  we 
learn  as  to  sickness  during  infancy  and  childhood  ;  as  to  the  period 
when  walking  began  ;  whether  there  was  any  bodily  deformity  observed 
at  birth  or  any  manifested  since ;  whether  any  injury  to  the  pelvic 
joints  or  dislocation  of  one  of  the  femurs  occurred  in  early  life  or  in 
adolescence;  whether  one  hip  is  higher  than  the  other,  or  either  femur 
is  ankylosed.  The  vertebral  column  is  examined  for  deformity,  whether 
apparent  or  latent ;  if  it  presents  a  deforming  curvature,  the  period  of 
its  first  manifestation  is  inquired  for,  such  curvature,  if  appearing  in 
infancy,  was  most  probably  caused  by  rickets ;  and  this  origin  will  be 
confirmed  by  finding  the  lower  limbs  notably  curved.  In  this  case  the 
pelvis  is  in  almost  all  cases  deformed.  But  if  the  spinal  curvature 
began  during  adolescence,  the  cause  is  not  rickets  and  the  pelvis  may  be 
normal.  The  woman  is  lame,  the  first  manifestation  and  cause  of  that 
lameness  should  be  ascertained.1 

If  the  woman  has  previously  been  delivered,  we  inquire  as  to 
whether  the  labor  was  natural  or  artificial,  whether  the  child  was  born 
living  or  dead,  and  in  case  of  instrumental  delivery  what  means  were 
employed.  If  possible,  too,  ascertain  further  as  to  the  cause  of  the 
difficulty  in  the  previous  labor  or  labors,  for  that  may  have  been  from  an 
abnormal  presentation  or  from  excessive  size  of  the  child.  It  should 
also  be  remembered,  on  the  other  hand,  that  though  the  first  labor  may 
have  been  spontaneous,  there  might  still  be  some  narrowing  of  the 
pelvis,  which  would  render  subsequent  ones  difficult  from  the  increasing 
size  of  the  children. 

CERTAIN  SIGNS.  As  before  stated,  the  positive  proofs  of  pelvic 
deformities  are  obtained  by  measurements  of  the  pelvis,  or  pelvimetry. 
These  measurements  are  made  by  an  instrument  called  a  pelvimeter, 
by  an  ordinary  tape-measure,  and  by  the  hand  or  fingers.  The 
pelvimeter  most  generally  employed  is  that  of  Baudelocque  or  that 
of  Martin ;  the  latter  instrument  has  the  recommendation  of  being 
quite  portable,  and  is  represented  in  use  in  Fig.  189.  In  using  the 
pelvimeter  the  woman  should  be  lying  upon  her  back,  and  the  lower 
portion  of  the  body  exposed,  or  at  least  covered  with  only  one  thick- 
ness of  very  thin  material.  Before  beginning  to  measure,  the  obste- 
trician applies  his  hands  externally  to  the  pelvis,  ascertaining  whether 
one  hip  is  higher2  than  the  other,  finds  out  whether  there  is  decided 
narrowing  of  the  hips,  the  thickness  and  size  of  the  iliac  bones,  the 

1  Peu,  La  Pratique  des  Accouchemens,  Raris,  1695,  makes  the  following  statement,  which  is 
interesting  as  one  of  the  earlier  obstetric  references  to  deformed  pelvis,  and  as  also  showing  that 
this  wise  observer  could  not  be  beguiled  by  beauty,  intellect,  wealth,  and  social  position  into 
marrying  a  young  lady  whom  he  believed,  from  her  lameness,  had  a  deformed  pelvis :  "  I  remember 
that  at  the  time  of  the  second  Paris  war,  having  recently  settled,  it  was  proposed  to  me  to  marry 
a  beautiful  young  lady,  rich,  very  spirituelle,  and  one  whose  father  I  greatly  honored ;  but  she 
was  small  and  lame  in  one  lower  limb.  The  consequences  of  the  lameness  which  I  apprehended 
prevented  me  from  making  this  alliance.  One  of  our  aspirants  in  surgery,  braver  than  I,  or  per- 
haps more  unfortunate,  fell  in  love  with  her  and  married  her.  Unfortunately,  she  became  preg- 
nant. Shortly  her  abdomen  touched  the  ground,  and  she  fell  from  the  slightest  misstep.  Her 
frequent  falls  compelled  her  to  lie  in  bed.  Her  child  died,  and  she  also  when  about  eight  months 
pregnant." 

Further  reference  to  lameness  as  indicating  deformity  is  given  by  Dionis,  Traite  general  des 
Accouchemens,  1718.  He  has  remarked  that  "  the  lame  who  have  one  of  the  hip-bones  higher 
than  the  other  sometimes  have  great  difficulty  in  labor,  because  the  basin  formed  by  these  bones 
is  not  exactly  round,  and  the  infant  is  obliged  to  redouble  its  efforts  in  order  to  go  through  the 


2  Want  of  symmetry  in  this  respect  is  so  common  as  to  be  the  rule,  and  it  is  only  a  marked 
deviation  that  should"  awaken  the  suspicion  of  the  examiner. 

32 


498  THE  PATHOLOGY  OF  LABOE. 

depth  of  each  iliac  fossa,  the  breadth  and  curvature  of  the  sacrum,  and 
the  height  of  the  pubic  joint.  Next  the  external  measurements  are 
made  :  first,  the  distance  between  the  anterior  superior  spinous  processes 
of  the  iliac  bones,  one  of  the  knobs  of  the  pelvimeter  touching  the  one 
processs,  and  the  other  placed  upon  that  of  the  opposite  side ;  this 
is  usually  25  centimetres,  or  about  ten  inches ;  second,  the  greatest 
distance  between  the  iliac  crests  at  their  external  margin  is  similarly 
ascertained;  this  diameter  is  28  centimetres,  or  11  inches.1  The  third 
measurement  made  is  that  between  the  great  trochanters ;  this,  in  case 
of  a  normal  pelvis,  is  31  centimetres,  or  12^  inches.  If  these  three 
diameters  are  normal,  we  know  that  there  is  no  lateral  narrowing  of 
the  pelvis.  The  fourth  measurement  is  taken  from  the  spinous  process 
of  the  last  lumbar  vertebra  to  the  middle  of  the  anterior  surface  of  the 
pubic  joint.  This  diameter,  known  as  the  external  conjugate  or  the 
diameter  of  Baudelocque,  enables  us  to  approximate  the  probable  antero- 
posterior  diameter  of  the  pelvic  inlet,  or  the  true  conjugate  ;  the  former 
measures  20  centimetres  (7.9  inches),  and  by  deducting  from  it  8  cen- 
timetres2 (3.1  inches)  the  latter  is  approximately  ascertained ;  such 
deduction  is  supposed  to  correspond  with  the  combined  thickness  of  the 
pelvic  walls,  anteriorly  and  posteriorly.  But  the  only  absolutely  certain 
fact  which  we  reach  by  measuring  this  diameter  is,  that  if  the  distance 
be  notably  diminished  the  true  conjugate  is  less  than  normal.3 

Litzmann  asserts  that  sometimes  the  measurement  of  the  distance  between  the 
posterior-superior  iliac  spines  may  be  useful  in  the  diagnosis  of  the  form  of  the 
pelvis.  The  relation  between  this  and  the  distance  between  the  antero-superior 
iliac  spines  varies  in  the  normal  and  in  the  uniformly  contracted  pelvis  between 
1  to  3  and  to  3.3 ;  in  the  flat  rhachitic  pelves,  1  to  3.5 ;  in  rhachitic  flat  and 
generally-contracted  pelves,  1  to  3.9 ;  and  in  the  simply  flat  rhachitic  pelves,  1 
to  4.3. 

The  diagonal  diameters  extend  from  the  postero-superior  iliac  spines  to  the 
antero-superior  spines,  passing  from  the  right  to  the  left,  and  from  the  left  to  the 
right;  if  the  pelvis  be  symmetrical  they  are  equal,  or  the  difference  is  very 
small.  They  are  each  about  22.5  centimetres,  and  if  normal  indicate  that  the 
corresponding  diameters  of  the  inlet  are  also  normal. 

Lohlein  has  sought  to  learn  the  transverse  diameter  by  measuring  from  the 
inferior  margin  of  the  subpubic  ligament  to  the  upper  angle  of  the  sciatic  notch 
and  adding  to  it  20  mm.  While  this  method  gives  a  correct  result  in  the  normal, 
it  is  without  value  in  the  abnormal  pelvis. 

In  the  great  majority  of  cases  the  obstetrician  will  be  content  with  measuring 
the  distances  between  the  iliac  crests  and  the  antero-superior  iliac  spines,  and 
the  external  conjugate,  so  far  as  external  pelvimetry  is  concerned.  Pershing,  in 
a  valuable  paper*  published  a  few  years  ago,  after  urging  the  importance  of  ex- 
amining the  pelvis  of  every  pregnant  woman,  adds:  ''The  examination  should 
consist  in  measurement  of  the  external  conjugate,  and  anterior  and  posterior 
iliac  spines,  and  iliac  crests.  If  these  external  measurements  indicate  a  normal 
pelvis,  the  examination  may  end  with  them.  But  if  contraction  is  suspected, 

i  Litzmanu,  Die  Geburt  bei  Engen  Becken,  states  that  in  200  women  with  a  large  pelvis,  he 
found  these  measurements  27  and  29.  5  centimetres.  Winckel  states  them  to  be  26  and  28,  while 
Zweifel  gives  the  numbers  in  the  text. 

8  Litzmann  states,  op.  cit,  that  in  30  cases  in  which  he  had  an  opportunity  of  comparing  the 
external  conjugate  measured  upon  the  living  with  the  true  conjugate  measured  upon  the  cadaver 
or  upon  the  dried  pelvis,  he  iound  a  mean  difference  of  9.5  centimetres,  with  a  maximum  of  12.5 
and  minimum  of  7  centimetres. 

8  If  the  external  conjugate  measures  less  than  16  centimetres  the  pelvis  is  always  narrowed 
antero-posteriorly  ;  if  below  19  centimetres  there  is  narrowing  in  one-half  the  cases,  between  19 
and  21.5  scarcely  once  in  ten,  and  above  21.5  almost  never.  (Litzmann.) 

4  Pelvic  Measurements  and  their  Importance  in  Obstetric  Practice,  American  Journal  of  the 
Medical  Sciences,  February,  J889. 


ANOMALIES  OF  THE  PELVIS. 


499 


the  diagonal  conjugate  and  oblique  ascending  diameter  of  Lohlein  should  also 
be  taken." 

The  circumference  of  the  upper  or  false  pelvis  is  formed  by  applying 
the  end  of  an  ordinary  tape-measure  to  the  spinous  process  of  the  last 
lumbar  vertebra,  and  carrying  the  tape  along  the  iliac  crest  of  one  side, 
and  thence  to  the  median  line  at  the  pubic  joint;  similarly,  the  other 
half  is  measured,  the  results  added,  and  thus  the  entire  circumference  is 
ascertained.  Evidently,  if  the  one  measurement  is  greater  than  the 
other,  the  pelvis  is  asymmetrical.  The  normal  circumference  of  the 
false  pelvis  is  90  centimetres  =  35.5  inches. 

FIG.  189. 


MEASURING  THE  EXTERNAL  CONJUGATE  WITH  MARTIN'S  PELVIMETER. 

Next,  the  diagonal  conjugate — that  is,  the  distance  from  the  lower 
margin  of  the  pubic  joint  to  the  promontory  of  the  sacrum — is  found 
usually  by  means  of  one  or  twd  fingers.  In  the  following  illustration 
the  index  and  medius  of  the  left  hand  are  extended,  the  thumb  ab- 
ducted, and  the  third  and  fourth  fingers  folded  upon  the  palm ;  the 
extended  fingers  are  carried  up  and  backward  in  the  pelvic  cavity 
until  the  promontory  is  touched  ;  then,  still  keeping  up  this  contact, 
the  hand  is  brought  upward  until  its  lateral  margin,  just  below  the 
index  finger  comes  in  contact  with  the  subpubic  ligament.  Next,  this 
last  point  is  marked  by  the  nail  of  the  index  finger  of  the  right  hand ; 
then  the  left  hand  is  withdrawn,  and  the  measurement  made  from  this 
mark  to  the  tip  of  the  finger.  Kleinwachter  holds  that  the  introduction 
of  the  index  and  medius  at  the  same  time  ought  not  to  be  permitted, 


500 


THE  PATHOLOGY  OF  LABOR. 


except  perhaps  in  the  case  of  a  multigravida,  because  the  stretching  of 
the  soft  parts  by  two  fingers  will  cause  pain ;  but  he  adds  that  in  very 
difficult  cases  the  half  or  the  whole  hand  may  be  used.  There  is  diffi- 
culty in  reaching  the  promontory  if  the  pelvis  is  normal,  but,  of  course, 
it  is  more  accessible  as  the  true  conjugate  is  lessened. 


MEASURING  THE  DIAGONAL  CONJUGATE. 

If  the  basin  be  normal,  the  true  conjugate  may  be  found  by  sub- 
tracting 15-16  millimetres  (-fa- fa  of  an  inch)  from  the  diagonal  con- 
jugate. "  It  is  evident  that  this  subtraction  will  vary  according  to 
the  angle  which  the  true  conjugate  makes  with  the  pubic  symphysis, 
and  as  to  the  height  of  the  symphysis.  It  is  increased  with  the 
obtuseness  of  the  angle  and  with  .  the  elevation  of  the  symphysis. 
Hence,  with  the  various  pelvic  deformities  the  subtraction  will  vary. 
Though  the  height  and  thickness  of  the  symphysis  may  be  ascertained, 
but  not  the  angle  which  it  forms  with  the  true  conjugate,  the  latter  can 
only  be  estimated,  and  hence  slight  errors  may  be  made.  Nevertheless, 
with  proper  skill  the  length  of  the  true  conjugate  may  be  determined 
within  a  few  millimetres,  and  the  error  is  so  slight  that  it  may  be 
regarded  as  of  no  importance." 

Measurements  of  the  diameters  of  the  pelvic  outlet  are  of  much  less  impor- 
tance ;  nevertheless,  they  may  be  required  in  some  cases.  To  obtain  the  antero- 


ANOMALIES  OF  LABOR.  501 

posterior  diameter,  the  woman  lies,  for  example,  upon  her  left  side,  and  the 
obstetrician  with  the  thumb  and  index  finger  of  the  right  hand — the  former 
externally,  the  latter  in  the  vagina— finds  the  sacro-coccygeal  joint,  and  includes 
it  between  them.  The  end  of  the  finger  is  fixed  at  that  point,  while  the  body  of 
the  finger  is  carried  forward  and  upward  until  its  lateral  surface  is  brought 
against  the  subpubic  ligament,  and  while  held  firmly  in  that  position  is  marked 
by  the  nail  of  the  index  finger  of  the  other  hand,  as  in  ascertaining  the  diagonal 
conjugate.  Upon  withdrawing  the  finger  the  distance  from  the  mark  to  the  tip 
is  measured,  and  this  will  give  the  desired  diameter.  Breisky  places  one  of  the 
knobs  of  the  pelvimeter  externally  at  the  sacro-coccygeal  joint,  while  the  other 
is  put  at  the  lower  margin  of  the  pubic  joint;  now  subtract  from  the  measure 
thus  obtained  1  to  1.5  centimetres,  and  we  then  have  the  antero-posterior 
diameter.  Breisky  recommends  for  measuring  the  transverse  diameter  of  the 
pelvic  outlet  Osiander's  pelvimeter.  The  knobs  are  placed  upon  the  ischial 
tuberosities,  and  from  the  measure  thus  obtained  of  the  intervening  distance 
between  the  tuberosities,  1-2  centimetres  must  be  subtracted  for  the  thickness 
of  the  soft  parts.  Frankenhauser's  method  is  to  place  the  thumbs,  their  nails 
being  directly  opposite,  upon  the  most  prominent  surface  of  the  inner  margin  of 
the  ischial  tuberosities,  and  then  with  Osiander's  pelvimeter  measure  the  dis- 
tance between  the  nails. 

Barbour1  states  that  the  transverse  diameter  of  the  outlet  is  best  estimated 
by  ChantreuiPs  method:  "Place  the  patient  in  the  genu-pectoral  position  or  in 
that  of  lithotomy,  though  the  former  facilitates  the  measuring ;  pass  the  index 
fingers  into  the  vagina,  and  turn  them  back  to  back  so  that  the  pulp  of  the  finger 
rests  on  the  inner  surface  of  the  ischial  tuberosities  ;  an  assistant  lays  the  points 
of  the  calipers  on  the  palmar  surface  of  the  fingers  just  outside  the  vulva,  the 
distance  intervening  corresponds  to  the  inside  measurement  between  the  tuber- 
osities. This  allows  us  to  use  the  ordinary  calipers." 

DIAGNOSIS  OF  THE  JUSTO-MINOR  PELVIS.  The  distances  between 
the  iliac  anterior  superior  spinous  processes  and  between  the  iliac  crests 
are  found  less  than  normal  in  all  cases,  an  exception  being  made  for  the 
masculine  pelvis,  for  in  it,  in  consequence  of  the  increased  thickness  of 
the  bones,  these  differences  may  be  very  slight  or  even  absent.  The 
pelvic  circumference  is  lessened,  as  is  also  the  true  conjugate.  Contrac- 
tion at  the  outlet  will  be  suggested  by  the  apparent  approximation  of 
the  ischial  tuberosities  and  spines,  and  be  confirmed  by  ascertaining 
that  the  antero-posterior  and  the  transverse  diameters  are  under  the 
normal. 

LABOR  AND  ITS  TREATMENT  IN  THE  GENERALLY-CONTRACTED 
PELVIS.2  Labor  begins  with  the  fnetal  head  at  the  pelvic  inlet,  for  there 
is  not,  as  there  is  in  the  majority  of  primigravidse3  having  a  normal 
pelvis,  descent  of  the  head  into  the  pelvic  cavity  during  the  last  weeks 
of  pregnancy.  The  resistance  of  the  lessened  inlet  compels  strong 
flexion  of  the  head  upon  the  chest,  and  thus,  with  the  occiput  below, 
the  head  enters,  the  biparietal » diameter  corresponding  with  the  con- 
jugate, and  the  suboccipito-bregmatic  with  the  transverse ;  the  sagittal 
suture  is  at  first  usually  in  the  transverse  diameter.  The  uniformity  of 
the  pelvic  contraction  shows  itself  by  the  strong  resistance  to  any  less- 

1  Spinal  Deformity  in  Relation  to  Obstetrics. 

2  Lizmann,  in  considering  the  question  what  should  be  understood  by  a  contracted  pelvis, 
states  that  for  the  simply  fiat  pelvis,  and  perhaps  also  for  the  generally-contracted  flat  pelvis, 
shortening  of  the  true  conjugate  to  about  9.7  centimetres  constitutes  the  boundary  line  between 
the  contracted  pelvis  and  the  pelvis  of  normal  size,  while  for  the  pelvis  uniformly  contracted  the 
limit  of  the  true  conjugate  is  10  centimetres. 

3  Litzmann  found  partial  entrance  of  the  head  in  8.1  per  cent,  at  the  end  of  pregnancy,  and  that 
in  scarcely  one-fourth  of  the  cases  after  labor  had  begun  did  descent  of  the  head  occur  before 
rupture  of  the  bag  of  waters. 


502  THE  PATHOLOGY  OF  LABOR. 

ening  of  flexion,  there  being  such  constant  and  great  pressure  upon  the 
frontal  arm  of  the  head- lever. 

Zweifel,  in  describing  the  mechanism  of  labor  in  generally-contracted 
pelves,  says  the  sagittal  suture  may  sometimes  be  in  the  transverse  or 
in  the  oblique,  or  even  in  the  antero-posterior,  pelvic  diameter,  and 
hence  the  child's  head  becomes  elongated.  This  elongation,  however, 
cannot  be  in  the  occipito-mental  diameter,  but  rather  in  that  described 
by  Budin  as  the  maximum  diameter,  for  the  squamous  portion  of  the 
occipital  bone  is  pushed  under  the  parietal  bones,  this  movement  being 
permitted  by  the  cartilaginous  connection  between  it  and  the  basilar 
portion.  So,  too,  the  equally  strong  compression  to  which  the  head  is 
subjected  on  all  sides  compels  overriding  of  the  frontal  by  the  parietal 
bones,  while  the  posterior  of  the  latter  overrides  the  anterior.  The 
caput  succedaneum  is  large  and  long,  even  in  some  cases  protruding 
from  the  vulval  opening  while  the  head  is  in  the  cavity. 

FIG.  191. 


MARKED  FLEXION  OF  THE  HEAD  ENTERING  A  GENERALLY-CONTRACTED  PELVIS. 

The  duration  of  labor  is  about  one-third  longer  than  if  the  pelvis  is 
normal.  From  the  head  remaining  so  long  at  the  pelvic  brim  while 
strong  uterine  contractions  are  going  on,  there  is  danger  of  injury  to 
some  portions  of  the  lower  uterine  segment,  resulting  in  subsequent 
inflammation,  or  actual  perforation  caused  by  long-continued  attrition. 
So,  too,  exhaustion  may  come  on  to  such  degree  that  the  life  of  the 
mother  is  imperilled,  the  uterus  falling  into  a  state  of  atony.  The 
long  continuance  of  the  labor  carries  danger  to  the  foetus,  and  injury 
may  also  result  from  the  strong  compression  of  its  head. 

Delay  in  rupture  of  the  membranes  until  the  os  is  fully  dilated, 
descent  of  the  occiput  rather  than  of  any  other  part  of  the  foetus, 
moderate  size  of  the  foetus,  yielding  character  of  the  bones  of  the  head, 
and  on  the  part  of  the  mother  a  slight  degree  of  pelvic  contraction  and 
vigorous  uterine  and  voluntary  action,  have  been  correctly  stated  to  be 
propitious,  the  labor  under  these  circumstances  usually  terminating 
favorably  for  both  mother  and  child. 

On  the  other  hand,  early  rupture  ot  the  membranes,  great  size  of  the 
child,  unyielding  nature  of  the  cranial  bones,  and  unfavorable  presenta- 
tion— as,  for  example,  of  the  pelvis  (usually  a  knee  or  foot  descends 


ANOMALIES  OF  THE  PELVIS.  503 

first  because  of  the  difficulty  of  the  pelvis  entering  the  inlet),  of  the 
brow,  or  a  shoulder — make  the  prognosis  unfavorable. 

The  mortality  of  children  Litzmann  states  is  9.5,  and  that  of  mothers 
a  little  more  than  6  per  cent. 

The  forceps1  is  not  applicable  in  general  contraction  of  the  pelvis 
until  the  head  is  completely  moulded.  So,  too,  podalic  version  is  not 
indicated  if  the  head  presents,  for  extraction  after  turning  cannot  be 
effected  soon  enough  to  save  the  child's  life ;  the  head  must  be  moulded 
to  the  passage  in  a  few  minutes — a  process  which  Nature's  forces  require 
hours  to  accomplish.  Further,  if  craniotomy  should  finally  become 
necessary,  the  difficulties  of  the  operation  are  increased  because  of  the 
head  coming  last.  Another  objection  to  delivery  by  podalic  version  is 
the  danger  of  ascension  of  the  arms  in  consequence  of  the  pelvic  con- 
traction. In  those  cases  in  which  the  contraction  is  chiefly  at  the  inlet 
the  mechanism  of  labor  after  the  head  has  entered  the  cavity  is  the  same 
as  in  a  normal  pelvis,  and  the  treatment  also  corresponds. 

3.  Anomalies  of  the  pelvic  form  or  asymmetrical  changes  in  the  pelvis. 
Two  divisions  of  this  class  are  made,  the  first  including  changes  in  the 
depth  of  the  pelvis  : 

a.  That  in  which  the  vertical  diameters  of  the  pelvis  are  increased, 
without  a  corresponding  change  in  the  horizontal.  Such  change  in- 
creases the  depth  of  the  pelvis,  but,  alone,  does  not  to  an  important 
degree  modify  the  course  of  the  labor;  the  latter  will  be  longer,  and  in 
some  cases  its  protraction  may  require  the  use  of  the  forceps. 

6.  The  second  class  embraces  those  pelves  whose  depth  is  lessened. 
But  this  change  is  in  almost  all  instances  associated  with  what  are  com- 
monly called  pelvic  deformities.  If  occurring  independently,  all  the 
horizontal  diameters  being  normal,  other  conditions  being  favorable,  the 
duration  of  labor  is  shortened. 

The  second  division  is  much  more  important,  and  includes  those 
changes  which  deform,  render  asymmetrical,  or  vitiate  the  pelvis.  It 
embraces  three  varieties:  1,  those  characterized  chiefly  by  shortening 
of  the  antero-posterior  diameter;  2,  a  like  change  in  the  transverse; 
and,  3,  the  same  in  the  oblique  diameter. 

The  following  subdivisions  are  made  of  these  three  classes  of  pelvic 
deformities.  These  subdivisions  are  those  adopted  by  Zweifel : 

I.  Pelves  chiefly  contracted  in  the  autero-posterior  diameter  : 
a.  The  flat  pelvis ; 
6.  The  rhachitic  flat  pelvis  ; 

c.  The  generally-contracted  flat  pelvis  ; 

d.  The  spondylolisthetic  pelvis;- 

e.  The  pelvis  flattened  by  double  luxation  ; 
/.  The  lumbo-lordotic  pelvis. 

The  last  originates  in  lordosis  of  the  lumbar  vertebrae,  which  is  com- 
pensated by  a  deeply  situated  kyphosis.  In  consequence  of  the  lordosis 
the  lumbar  vertebrae  may  project  over  the  pelvic  entrance,  causing  the 
deformity  known  as  pelvic  obtecta,  or  roofed  pelvis.  In  the  osteomalacic 
pelvis,  to  be  described  in  the  next  class,  there  is  also  considerable  con- 
traction in  the  antero-posterior  diameter  : 

1  Kleinwachter. 


504  THE  PATHOLOGY  OF  LABOR. 

II.  Pelves  chiefly  contracted  in  the  transverse  diameter  : 
a.  The  osteoraalacic  pelvis  ; 

6.  The  ankylotic  transversely  contracted  pelvis ; 
c.  The  kyphotic  transversely  contracted  pelvis. 
In  6  and  c  the  narrowing  is  only  in  the  pelvic  outlet. 

III.  Pelves  chiefly  contracted  in  their  oblique  diameter  : 
a.  The  ankylotic  obliquely  contracted  pelvis  ; 

6.  The  coxalgic  pelvis; 
c.  The  scoliotic  pelvis. 

Neoplasms  originating  in  the  pelvic  walls  constitute  a  final  class  of 
pelvic  deformities. 

THE  SIMPLE  FLAT  PELVIS.  This  pelvis  may  be  found  in  women 
who  present  no  other  anomaly  of  form  which  would  awaken  the  slightest 
suspicion  of  its  presence.  They  are  usually  of  normal  stature  and  appar- 
ently of  perfect  development.  There  is  no  history  of  disease  of  the 
bones  in  infancy  or  childhood,  or  of  injury  to  spine  or  pelvis  or  lower 
limbs  in  adolescence.  How  often  has  this  anomaly  led  to  the  most 
deplorable  results  in  childbirth  !  Even  in  Europe  this  pelvis  is  found 
a  little  more  frequently  than  the  rhachitic,  while  the  American  obste- 
trician will  meet  with  it  oftener  than  any  other  pelvic  anomaly,  and  thus 
forewarned  ought  to  be  forearmed. 

The  cause  of  the  deformity  is  not  clear.  The  deformity  consists 
essentially  in  an  approximation  of  the  sacral  promontory  to  the  anterior 
pelvic  wall,  and  the  sinking  of  the  sacrum  has  been  attributed  to  walk- 
ing too  early,  to  sitting  too  long  at  a  time  in  infancy,  and  also  simply 
to  the  weight  of  the  body,  when  neither  of  the  other  causes  can  be  justly 
adduced.  Still  another  explanation  of  the  etiology  has  been  suggested — 
the  carrying  of  heavy  weights  in  childhood  ;  but  the  occurrence  of  the 
anomaly  in  women  who  were  never  subjected  in  childhood  to  severe 
toil  renders  necessary  the  explanation  that  has  been  given — viz.,  the 
simple  weight  of  the  body  may  cause  the  deformity. 

The  descent  of  the  sacrum  is  without  any  rotation  upon  its  transverse 
axis,  and  the  approximation  of  this  bone  to  the  pubic  bones,  and  the 
shortening,  involve  only  the  antero-posterior  diameter  of  the  inlet,  or  if 
those  of  the  cavity  and  outlet  are  lessened  the  diminution  is  very  slight. 
The  descent  causes  strong  tension  upon  the  ilio-sacral  ligaments,  which 
would  result  in  separation  of  the  iliac  bones  if  it  were  not  for  the  re- 
sistance of  the  pubic  joint ;  and  the  consequence  is  that  the  transverse 
diameter  undergoes  slight  increase  and  the  pubic  joint  is  brought  nearer 
the  sacrum. 

Schroder  states  that  in  very  rare  cases  a  flattened  pelvis  is  also  nar- 
rowed in  the  transverse  diameter  of  the  outlet.  In  a  practical  point  of 
view,  this  is  a  very  important  complication  of  the  flattened  pelvis, 
sometimes  the  articulation  of  the  first  with  the  second  sacral  vertebra, 
which  remains  unossified,  forms  that  which  is  called  a  double  promon- 
tory ;  that  is  to  say,  the  two  vertebrae  meet  at  an  obtuse  angle  poste- 
riorly, and  the  articulation  makes  in  contracting  a  projection  in  the 
pelvic  cavity.1  If  a  line  bp  drawn  from  this  projection  to  the  pubic 

1  Schroder.  Nevertheless,  Zweifel  remarks  in  reference  to  the  name  given  this  pelvis,  that  we 
use  the  expression  simple,  einfach,  in  contradistinction  to  rhachitic.  By  this  term  Michaelis  first 
expressed  the  difference  between  the  single  and  double  promontory. 


ANOMALIES  OF  THE  PELVIS. 


505 


symphysis,  it  is  as  short  as,  or  even  shorter  than,  the  true  conjugate 
itself,  and,  as  this  anomaly  has  an  essential  obstetric  importance,  it  must 
be  included  in  pelvic  measurements. 

The  diagnosis  of  the  flat,  non-rhachitic  pelvis  is  readily  made  by 
measuring.  The  transverse  measurements  are  normal  or  slightly  in- 
creased ;  the  circumference  is  normal  or  slightly  decreased,  but  the  two 
sides  of  the  upper  pelvis  are  symmetrical ;  the  external  conjugate  is 
always  diminished,  and  by  this  diminution,  combined  with  that  of  the 
diagonal  conjugate,  the  true  conjugate  is  found,  which,  of  course,  is  less 
than  normal,  and  in  the  great  majority  of  cases  at  least  8  centimetres 
(3.1  inches). 

RHACHITIC  FLAT  PELVIS.  This  deformity  results  from  pressure 
upon  the  base  of  the  sacrum  chiefly,  causing  not  only  descent  of  the 
bone,  but  also  a  partial  anterior  rotation  upon  its  transverse  axis ;  thus 
the  promontory  is  brought  nearer  the  pubic  joint,  and  the  true  conjugate 
necessarily  shortened.  In  a  flat  rhachitic  pelvis  in  the  Museum  of 


FIG.  192. 


FLAT  RHACHITIC  PELVIS  (Mutter  Museum,  College  of  Physicians,  Philadelphia). 


Jefferson  Medical  College  I  find  the  following  measurements  of  the 
pelvic  inlet:  Oblique  diameter,  5  inches;  transverse,  5J  inches;  and 
true  conjugate,  3  inches.  The  measurements  of  the  outlet  are:  antero- 
posterior,  3f  inches,  and  the  transverse  4  inches.  The  depth  of  the 
pelvis  at  the  pubic  joint  is  1J  inch,  at  the  sides  2f  inches. 

Eickets  is  a  disease  occurring  in  infancy  or  early  childhood,  chiefly  charac- 
terized by  a  disorder  of  nutrition  and  development  of  bony  tissue,  the  disorder 
involving  various  deformities  of  the  skeleton,  swelling  of  the  epiphysis,  bending 
or  fractures  of  the  diaphysis,  important  changes  in  the  shape  of  the  pelvis,  and 
frequently  curvatures  of  the  spine.  While  in  almost  all  cases  it  is  a  disease  of 
extra-uterine  life,  yet  there  have  been  instances  in  which  it  occurred  in  utero, 
probably  the  first  recorded  one  being  given  by  Glisson  in  1650. 


506  THE  PATHOLOGY  OF  LABOR. 

It  is  a  disease  especially  of  poverty,  and  is  found  most  frequently  in  the  large 
cities  of  the  Old  World,  where  the  poor  abound  and  the  children  of  the  poor 
often  so  greatly  suffer  from  want  of  sufficient  food,  fresh  air  and  sunshine,  and 
proper  clothing.  Arnott1  speaks  of  its  being  frequent  in  India,  though  he  also 
states  that,  so  far  as  his  experience  goes,  osteomalacia  is,  relatively  to  rickets  and 
also  absolutely,  more  common  in  India  than  in  Europe. 

The  child  suffering  from  rickets  does  not  walk  so  early  as  healthy  children, 
but  is  much  of  the  time  in  a  sitting  posture ;  the  pressure  of  the  body's  weight 
causes  not  only  the  changes  in  the  position  of  the  sacrum  previously  stated,  but 
also,  through  the  resisting  tension  of  the  ilio-sacral  ligaments,  drawing  of  the 
innominate  bones,  so  that  they  would  separate  if  it  were  not  for  the  resisting 
pubic  joint ;  this  separation  being  impossible,  the  bones  yield,  and  hence  the 
transverse  diameter  of  the  inlet  is  increased,  "just  as  a  long  bone  may  be  frac- 
tured in  the  shaft  by  a  force  applied  at  one  end,  the  other  end  resisting."  In 
consequence  of  the  weight  of  the  body  resting  upon  the  ischial  tuberosities,  and 
by  the  action  of  muscular  traction,  the  former  are  more  widely  separated,  and 
also  the  pubic  rami,  and  the  pubic  arch  is  broadened. 

If  the  child  walks  during  the  disease,  the  pelvic  deformity  is  greatly  increased, 
there  being  superadded  the  changes  caused  by  pressure  upon  the  acetabula. 
"  The  parts  adjacent  to  the  acetabula  are  pressed  into  the  basin  by  the  resistance 
of  the  heads  of  the  femurs,  and  thus  the  sacro-cotyloid  diameters  are  lessened. 
In  consequence  of  the  approach  of  the  ilio-pubic  tubercles  the  ischial  spines  are 
pressed  in  the  pelvis ;  the  approximation  of  the  former  causes  a  beaked  protru- 
sion of  the  pubic  joint."  In  the  highest  degree  of  the  deformity  the  lumen  of 
the  pelvis  is  almost  closed,  and  with  bending  of  the  sacrum  and  iliac  bones  the 
pelvis  may  take  a  triangular  form  and  is  known  as  the  pelvis  triloba,  or  the 
pseudo-osteomalacic  pelvis. 

Turning  from  these  graver  deformities  of  the  pelvis  caused  by  rickets, 
we  will  now  consider  the  diagnosis  of  the  simply  flat  rhachitic  pelvis. 
The  history  of  rickets  is  learned,  and  many  of  its  obvious  consequences 

FIG.  193. 


PSEUDO-OSTEOMALACIC  PELVIS  (Mutter  Museum,  College  of  Physicians,  Philadelphia). 

in  other  parts  of  the  pelvis  may  be  present.  The  distance  between  the 
antero-superior  iliac  spines  is  equal  to,  possibly  exceeds,  that  between 
the  iliac  crests;  the  external  conjugate  is  always  lessened ;  the  true  con- 
jugate is  shortened  ;  in  some  instances  the  second  sacral  bone  protrudes 
into  the  pelvic  cavity,  making  what  is  called  the  false  promontory,  and 

1  Transactions  of  the  Edinburgh  Obstetrical  Society,  vol.  x. 


ANOMALIES  OF  THE  PELVIS. 


507 


this  may  be  more  prominent  than  the  true,  when,  of  course,  it  becomes 
one  of  the  terminal  points  of  the  conjugata  vera.  The  antero-posterior 
and  transverse  diameters  of  the  outlet  are  unusually  large  in  comparison 
with  the  contraction  at  the  inlet. 

THE  MECHANISM  OF  LABOR  IN  THE  SIMPLE  FLAT  AND  IN  THE 
RHACHITIC  FLAT  PELVIS.  In  consequence  of  the  narrowing  of  the 
pelvic  inlet,  the  head  of  the  foetus  not  only  does  not  enter  the  pelvic- 
cavity,  as  is  the  rule  in  the  last  weeks  of  pregnancy  in  primigravidse, 
but  it  may  be  turned  aside  at  the  brim,  and  hence  the  proportion  of 
transverse  presentations  is  increased.  Another  factor1  in  causing  such 
malposition  of  the  foetus  is  found  in  multigravidse  in  the  relaxed  abdom- 
inal and  uterine  walls,  which  permit  anterior  displacement  of  the 
uterus,  though  a  pendulous  abdomen,  as  Litzmann  observes,  is  especially 
frequent  in  pelvic  contraction,  and  in  these  cases  there  is  not  simple 
anteversion,  but  auteflexion  of  the  uterus.  If  the  pelvis  be  below,  its 
descent  through  the  narrowed  aperture  does  not  occur,  but  the  feet  are 
prone  to  enter.  Supposing  the  head  to  be  at  the  inlet  when  labor 
begins,  it,  as  a  rule,  takes  a  transverse  position ;  that  is,  the  sagittal 
suture  instead  of  being  oblique  lies  directly  from  one  side  toward  the 
other  of  the  pelvis.  Resistance  to  the  descent  of  the  occiput  compels  a 
partial  deflection,  and  the  anterior  and  posterior  fontanelles  may  be  in 
the  same  pelvic  plane ;  thus  the  transverse  diameter  of  the  foetal  head 
is  in  the  pelvic  conjugate,  and  the  occipito-froutal  in  the  pelvic  trans- 
verse. But  in  this  accommodation  the  anterior  parietal  is  somewhat  in 
advance  of  the  posterior,  and  therefore  the  sagittal  suture  approaches 
the  sacral  promontory.  (See  Fig.  194.) 

FIG.  194. 


HEAD  PASSING  THROUGH  THE  INLET  IN  FLAT  PELVIS. 

The  anterior  parietal  bone,  pressed  against  the  anterior  pubic  wall, 
according  to  the  description  of  Kleinwachter,  becomes  the  fixed  pivotal 
point  around  which  a  partial  revolution  of  the  posterior  parietal  occurs 
in  the  descent  until  the  promontory  is  cleared.  But  in  order  that  this 
descent  can  occur,  the  transverse  diameter  of  the  head  must  be  lessened  ; 

1  Kleinwachter. 


508  THE  PA  THOL  O  G  Y  OF  LA  B  OR. 

this  lessening  is  in  part  accomplished  by  the  lateral  margin  of  the  pos- 
terior parietal  passing  under  the  corresponding  part  of  the  anterior 
parietal.  In  some  instances  the  revolution  is  reversed ;  that  is,  the 
posterior  parietal  is  fixed  at  the  promontory,  while  the  anterior  moves 
down  ;  then  the  relations  of  the  parietals  are  changed,  in  that  the  pos- 
terior overrides  the  anterior.  Further  diminution  of  the  head  trans- 
versely may  be  effected  by  indentation,  deep  depressions,  or  even  frac- 
tures or  fissures  of  the  revolving  parietal.  After  the  head  has  passed 
the  inlet  the  subsequent  mechanism  is  the  same  as  in  normal  labor,  and 
often  then  the  delivery  is  more  rapid  from  the  ampler  space  furnished 
by  the  cavity,  and  especially  by  the  outlet  in  the  pelvis  flattened  by 
rickets,  as  has  been  previously  mentioned.  Nevertheless,  as  stated  by 
Litzmann,  often  the  uterine  contractions  fail  in  force  in  consequence  of 
exhaustion  from  the  prolonged  effort  made  in  forcing  the  head  through 
the  inlet,  so  that  the  delivery  must  be  completed  by  art. 

In  exceptional  cases  the  sagittal  suture  is  placed  so  near  the  pubic  or 
the  sacral  wall  of  the  inlet  that  what  is  termed  a  parietal  presentation 
results ;  if  this  presentation  is  not  rectified,  delivery  is  impossible  with- 
out craniotomy.  Descent  of  the  frontal  bone  first  may  occur  in  great 
narrowing  ;  then  the  two  halves  of  the  bone  play  a  corresponding  part 
to  that  of  the  parietals  in  relation  to  the  pubic  and  the  sacral  wall  of  the 
pelvis.  Whether  the  parietals  or  the  frontal  halves  pass  the  strait  first, 
the  posterior  bone  has  a  distinct  pressure-mark  from  its  being  so  strongly 
forced  against  the  promontory. 

In  pelvic  presentation  one  or  both  feet  usually  descend  first ;  if  the 
contraction  is  slight,  the  body  passes  through  it  without  serious  diffi- 
culty ;  then  the  head  may  pass  also — of  course,  it  must  be  in  a  trans- 
verse position  for  this  passage — flexion  being  continued ;  the  posterior 
parietal  bone  suffers  from  pressure  in  descending  the  promontory.  In 
more  decided  narrowing  departure  of  the  chin  from  the  chest  is  ob- 
served. 

The  mortality  of  mothers  is  more  than  7  per  cent.,  and  of  children 
50  to  60  per  cent.  The  prognosis  is  more  favorable  in  the  case  of 
female  than  of  male  children,  and  it  is  also  more  favorable  if  the 
woman  be  a  multipara  thau  if  a  primipara,  provided  the  head  presents. 

In  the  management  of  the  labor  care  should  be  taken  to  keep  the 
membranes  unruptured  until  the  os  is  dilated,  and  hasty  intervention 
while  the  head  is  being  moulded  to  pass  through  the  narrowed  inlet 
must  be  avoided.  If  nature  is  unable  to  effect  the  passage  of  the  head 
through  the  inlet,  resort  to  the  forceps  is  not  indicated,  but  podalio 
version.  In  regard  to  the  former  means,  Zweifel  observes  that  the 
application  of  the  forceps  to  the  movable  head  is  not  impossible,  but  to 
seize  it  firmly  is  purely  accidental ;  an  application  of  the  blades  over 
the  parietal  bones  is  absolutely  impossible;  and  even  if  the  head  were 
thus  grasped,  it  could  not  be  drawn  through  the  conjugate.  Version 
comes  only  in  those  cases  in  which  the  forceps  cannot  be  used  ;  and 
even  then  the  question,  as  Schroder  has  framed  it,  is,  Shall  we  turn,  or 
wait?  "  Whenever  we  perform  version  in  contracted  pelves  we  decide 
in  favor  of  this  operation  without  knowing,  in  case  this  is  not  done,  how 
the  head  would  enter  the  true  pelvis  and  how  it  would  pass  through. 


ANOMALIES  OF  THE  PELVIS.  509 

This  renders  the  question  as  a  practical  one  so  difficult,  and  will  prob- 
ably thus  keep  it  for  a  long  time,  probably  forever." 

The  usual  rule  is  to  wait  after  rupture  of  the  membranes  and  dilata- 
tion of  the  os,  with  the  hope  that  the  head  may  enter  and  pass  the 
inlet ;  but  if  after  a  reasonable  delay  this  does  not  occur,  podalic  version 
is  to  be  employed. 

GENERALLY-CONTRACTED  FLAT  PELVIS.  In  this  variety  there  is 
a  greater  degree  of  descent  of  the  sacral  promontory  than  is  found  in 
the  generally -contracted  pelvis,  and  the  deformity  rarely  occurs  except 
as  a  consequence  of  rickets.  Not  only  all  the  pelvic  diameters  are  below 
the  normal,  but  the  true  conjugate  especially  is  shortened. 

Litzmann  states  the  mortality  of  mothers  with  this  pelvic  deformity 
is  between  8  and  9  per  cent.,  and  of  children  delivered  dead  or  dying, 
there  are  66  per  cent. 

THE  SPONDYLOLISTHETIC  PELVIS  (from  a7r6i>6vhog,  probably,  more 
correctly,  c<j>6v6v^,  vertebra ;  and  oMcdr/aif,  a  slipping  or  gliding). 
This  deformity  arises  from  a  gliding  or  slipping  forward  of  the  last 
lumbar  vertebra,  so  that  it  no  longer  rests  upon  the  upper  surface  of  the 
first  sacral  vertebra  completely,  but  only  partially ;  or  even,  in  an 
excessive  degree  of  spondylolisthesis,  the  posterior  wall  of  the  body  of 
the  former  vertebra  maybe  fixed  to  the  anterior  wall  of  the  body  of  the 
latter,  a  synostosis  occurring.  Sometimes,  indeed,  the  lumbar  vertebral 
column  glides  down  to  the  body  of  the  second  sacral  vertebra.  The 
lumbar  vertebrae  thus  sinking,  lordosis  results,  and  the  lower  edge  of 
the  fourth  lumber  vertebra,  or  the  union  between  the  third  and  fourth, 
or  even  that  between  the  second  and  third,  is  opposite  the  pubic  joint. 

This  pelvis  was  first  described  by  Rokitansky.  The  question  as  to  the  cause 
of  the  deformity  has  been  much  discussed.  From  the  firmness  of  the  transverse 
processes  of  the  normal  vertebrae  it  would  seem  impossible  for  a  dislocation  of 
one  of  the  bodies  to  occur ;  and  the  view  generally  held  as  to  its  origin  in  the 
majority  of  cases  is  that  it  results  from  a  fracture  of  the  vertebral  arch  anterior 
to  the  articulating  processes — this  fracture  caused  by  a  fall  upon  the  sacrum — 
and  hence  dislocation  becomes  possible.  "  If  a  person  should  thus  fall  with  the 
body  bent  forward,  the  sacrum  being  fixed  at  the  moment  of  the  accident,  the 
force  will  mainly  act  upon  the  body  and  arch  of  the  last  lumbar  vertebra,  and  a 
fracture  of  the  acrh  would  very  probably  occur."  Zweifel  remarks  that  we  can- 
not overlook  the  weak  side  of  this,  F.  L.  Neugebauer's  theory,  which  is,  that 
hitherto  the  traces  of  such  a  healed  fracture  have  been  found  in  only  one  case.1 
Nevertheless,  he  also  states  that  a  traumatic,  and  hence  extra-uterine,  origin  of 
spondylolisthesis  must  be  admitted  for  the  majority  of  cases.  There  may  also 
be  congenital  spondylolisthesis,  the  origin  of  the  disease,  from  the  failure  of 
coalescence  of  ossification-centres  in  the  vertebral  arches,  thus  permitting  dislo- 
cation of  the  vertebral  body.  This  'deformity  is  rare ;  Kleinwachter,  writing  in 
1882,  states  that  only  fourteen  cases  have  been  observed. 

The  diagnosis  is  made  by  the  increased  distance  between  the  posterior 
superior  iliac  spines ;  by  the  marked  lordosis  just  above  the  sacrum  ; 
by  the  shortening  of  the  abdomen,  its  contents  sinking  so  much  between 
the  ilia;  by  the  peculiar  "  rocking  gait"  of  the  pregnant  woman,  by  the 
absence  of  any  history  or  present  manifestation  of  rhachitis  or  of  osteo- 
malacia ;  by  an  account  of  a  fall  such  as  would  result  in  fracture  of  the 

1  Winckel  mentions  two  cases  under  his  observation,  in  which  the  probability  was  that  the 
deformity  had  its  origin  as  Neugebauer  has  stated. 


510 


THE  PATHOLOGY  OF  LABOR. 


arch  of  the  fifth  lumbar  vertebra;  but,  above  all,  by  internal  examina- 
tion, counting  the  bodies  of  the  sacral  vertebrae,  and  recognizing  the 
projecting  lumbar  vertebra  by  finding  the  sacral  vertebrae  complete,  and 
by  the  absence  of  the  alee  in  this,  which  belong  to  the  first  sacral.  In 
Olshausen's  case,  the  bifurcation  of  the  aorta  could  be  felt  on  the  deeply- 
sunken  lumbar  vertebral  column. 


FIG.  195. 


SPONDYLOLISTHETIC  PELVIS,  SHOWING  DISLOCATION  INTO  THE  PELVIC  BRIM  OF  THE  LUMBAR 
VERTEBRA  (KILIAN).    THE  "  PRAGUE  PELVIS." 
4.  Fourth  vertebra.    5.  Fifth  lumbar  vertebra. 

The  Csesarean  operation  is  unavoidable  in  a  severe  spondylolistnesis. 
Slight  degrees  of  the  deformity  are  much  more  common  than  was  at 
first  supposed,  and  the  prognosis  is,  according  to  Zweifel,  no  more 
unfavorable  than  it  is  in  the  flat  rhachitic  pelvis. 

THE  PELVIS  FLATTENED  FROM  BILATERAL  DISLOCATION  OF  THE  FEMORAL 
BONES.  Whether  the  double  dislocation  be  congenital  or  occur  early  in  child- 
hood, the  heads  of  the  femurs  pressing  above  and  posteriorly  to  the  acetabula, 
"  great  traction  is  exerted  upon  the  round  and  upon  the  ilio-femoral  ligaments  ; 
the  muscles  of  rotation  passing  from  the  inner  side  of  the  pelvis  to  the  femur, 
the  obturators  and  gemelli  are  also  made  tense  Hence  traction  in  a  transverse 
line  at  the  pelvic  outlet  and  its  partial  eversion.  By  the  tension  of  the  ilio- 
femoral  ligaments  passing  from  the  capsule  to  the  anterior  inferior  spinous  pro- 
cess, and  in  consequence  of  the  place  of  support  of  the  trunk,  the  heads  of  the 
femurs,  being  placed  further  back,  the  centre  of  gravity  is  thrown  anterior  to  the 
plane  of  support ;  continual  care  is  necessary  to  prevent  falling  forward,  and  this 
is  exerted  by  the  dorsal  muscles  drawing  the  body  backward,  the  consequence  of 
which  is,  the  inclination  of  the  pelvis  is  lessened,  and  there  is  a  lumbar  lordosis. 
Tension  upon  the  pelvic  ring  causes  increase  in  the  transverse  diameter  of  the 
inlet  and  flattening  of  the  pelvis,  with  necessary  shortening  of  the  conjugate  ; 
the  latter  diminution  is  also  increased  by  sinking  of  the  sacrum."  Not  only  the 
conjugate  is  lessened,  but  usually  the  corresponding  diameters  of  the  cavity  and 
of  the  outlet,  though,  according  to  Kleinwachter,  this  lessening  becomes  less  at 


ANOMALIES  OF  THE  PELVIS. 


511 


the  outlet  in  consequence  of  the  recession  of  the  lower  part  of  the  sacrum,  while, 
on  the  other  hand,  it  may  be  that  resulting  from  tension  upon  the  ligamentous 
connections  between  the  ischial  tuberosities  and  spines  upon  the  lower  portion 
of  the  sacrum,  the  latter  is  drawn  forward,  and  then  there  necessarily  follows 
lessening  of  the  antero-posterior  diameter  of  the  outlet. 

The  true  conjugate  rarely  falls  below  nine  centimetres,  but  in  some  it  has  been 
reduced  to  seven.  The  characteristics  of  this  pelvis  are,  in  addition  to  the  les- 
sened conjugate,  the  increase  of  the  transverse  diameter,  the  fact  of  the  double 
luxation,  the  greater  breadth  of  the  pubic  arch,  the  lessened  pelvic  depth,  and 
the  flattening  of  the  pelvic  inlet.  The  diagnosis  in  the  living  subject  is  greatly 
facilitated  by  observing  the  duck-like  gait.  This  pel  vie  anomaly,  if  we  know  the 
peculiar  walk  of  those  having  such  a  basin,  Zweifel  states,  can  be  diagnosed  at 
a  distance  of  two  hundred  steps. 

This  variety  of  pelvic  deformity  is  quite  rare ;  according  to  Kleinwachter,  only 
nine  of  such  pelves  have  hitherto  been  observed.  The  labor  usually  ends  favor- 
ably both  for  mother  and  child ;  after  the  head  once  passes  the  inlet  the  progress 
is  quite  rapid. 

The  Second  Class  includes  Pelves  chiefly  Narrowed  in  the  Transverse 
Diameter. 

a.  The  osteomalacic  pelvis.  Osteomalacia  (from  barlov,  bone,  and 
nahaxbt,  soft — mollities  ossium,  softening  of  the  bone)  is  a  disease  of 
which  the  essential  cause  is  a  diminution  of  the  earthy  salts  of  the 
bones,  this  diminution  being  such  that  these  salts  are  two,  three,  or  even 
five  times  less  than  normal,  and  of  which  the  most  marked  results  are 

FIG.  196. 


OSTEOMALACIC  PELVIS,  SHOWING  THE  BEAK-LIKE  SHAPE  OF  THE  PUBES. 

changes  in  the  forms  of  the  bones  in  consequence  of  their  great  flexi- 
bility. It  is  not  a  disease  belonging  exclusively  to  adult  life,  nor  to 
the  female,  nor  to  childbearing.  Nevertheless,  the  statistics  of  Col- 
liueau  indicate  very  clearly  the  frequent  origin  of  the  disease  in  conse- 
quence of  changes  of  the  organism  caused  by  pregnancy.  He  found 
only  14  of  43  women  suffering  with  osteomalacia  who  had  never  been 
pregnant,  and  of  the  other  29,  14  who  had  had  from  four  to  ten  preg- 


51 2  THE  PA THOLOG  Y  OF  LABOR. 

nancies,  6  one  to  three,  and  4  who  had  been  pregnant  but  once.  Thus 
it  is  seen  these  statistics  prove  that  the  majority  of  cases  of  the  disease 
are  connected  with  pregnancy.  It  may  appear  during  gestation  or  in 
the  puerperium ;  once  begun,  the  disease  is  aggravated  by  succeeding 
pregnancies,  especially  if  the  intervals  are  short. 

It  is  impossible  to  explain  satisfactorily  the  anomaly  of  nutrition  which  is 
essential  to  the  disorder.  "  While  true  that  the  disease  has  never  been  observed 
in  women  comfortably  situated  in  life,  even  the  lack  of  good  nourishment,  mis- 
erable and  damp  dwellings,  a  diet  exclusively  of  potatoes  or  of  rice,  cannot  be 
regarded  as  the  absolute  cause  of  the  disease,  though  the  conditions  just  stated 
are  undoubtedly  predisposing  causes.  If  deficient  nourishment  of  the  bones  in 
the  large  majority  is  the  sole  cause,  so  that  the  bones,  losing  their  earthy 
elements,  are  softened,  then  osteomalacia  would  be  much  more  frequent.  A  fact 
that  is  inexplicable  is,  that  the  disease  occurs  usually  only  rarely  and  sporadically, 
but  in  some  countries  very  frequently,  so  that  it  may  be  called  endemi<?;  thus  it 
is  found  on  the  banks  of  the  lower  Rhine  and  in  the  adjacent  valleys,  in  East 
Flanders,  and  on  the  plains  of  the  Po."  The  fact  of  its  frequently  being  seen  in 
India  has  previously  been  stated. 

The  changes  in  the  spinal  column  and  in  the  pelvis  result  from  softening  ot 
the  bones  affected  by  pressure  and  by  traction.  The  spinal  column,  corresponding 
to  its  normal  curvatures,  is  pressed  by  the  weight  of  the  body,  and  hence  follow 
kyphoses,  kypho-scolioses,  and  lordoses.  "The  weight  of  the  body  causes  by  its 
pressure  upon  the  sacrum  pushing  of  the  promontory  downward  and  forward,  and 
the  sacrum  draws  anteriorly  the  posterior  halves  of  the  ilia,  so  that  they  are 
bent.  The  sacrum  is  narrowed,  especially  from  lessened  expansion  of  the  alse, 
and  it  is  also  bent  forward.  The  pressure  from  the  femurs  forces  the  acetabula 
and  adjacent  parts  inward  and  upward,  so  that  the  pubic  joint  and  horizontal 
rami  are  pressed  forward,  the  rami  becoming  parallel  and  proximate,  so  that  the 
ilio-pectineal  eminences  are  adjacent."  The  illustration  given  shows  the  beak- 
like  projection  of  the  pubic  joint — pelvis  rostrata.  The  pubic  arch  almost 
entirely  disappears,  and  while  the  antero-posterior  diameter  of  the  inlet  may  be 
increased,  the  available  space  is  seriously  lessened.  The  pressure  upon  the 
acetabula  always  makes  the  outlet  less  than  the  inlet. 

In  making  the  diagnosis  of  deformity  of  the  pelvis  from  osteomalacia, 
the  history  is  of  great  importance ;  for  example,  the  period  when  the 

FIG.  197. 


ROBERT'S  PELVIS. 


disease  was  first    manifested — just   following   pregnancy;    the   severe 
pains  felt — tearing  and  drawing,  mistaken  in  some  cases  for  violent 


ANOMALIES  OF  THE  PELVIS. 


513 


rheumatism.  The  patient's  walk  is  characteristic,  for  in  consequence  of 
the  approximation  of  the  acetabula  the  femurs  are  brought  near,  and 
she  is  compelled  at  each  step  to  turn  on  one  foot,  while  the  other  is 
thrown  around  and  in  front  of  it.  Those  affected  with  the  disease  are 
small,  and  as  it  progresses  they  grow  smaller. 

The  bistrochanteric  diameter  is  lessened  ;  the  external  conjugate  is 
not  lessened  in  all  cases,  but  the  promontory  is  always  accessible,  the 
narrowed  pubic  arch  and  the  approximated  horizontal  pubic  rami  giving 
a  beaked  form  to  the  anterior  portion  of  the  pelvis ;  and,  finally,  the 
diminished  outlet  will  be  more  or  less  readily  recognized. 

A  general  rule  in  regard  to  the  conduct  of  labor  in  a  case  of  osteo- 
malacic  pelvis  is  not  to  interfere  too  early,  for  the  bones  may  prove  so 
yielding  under  uterine  contractions  that  the  passage  for  the  foetus  is 
opened,  and  thus  Csesarean  section  or  embryotomy  be  averted.  Because 
of  the  yielding  of  the  pelvic  bones  to  the  pressure  of  labor,  the  pelvis 
has  sometimes  been  called  the  India-rubber  pelvis. 

FIG.  198. 


LUMBO-SACRAHKYPHOSIS  (Mutter  Museum,  College  of  Physicians,  Philadelphia). 

i 

b.  The  ankylotic  transversely-eontraeted  pelvis.  The  first  pelvis  of 
this  kind  was  described  by  Robert  in  1842.  Its  origin  seems  to  be 
in  an  arrested  or  imperfect  development  of  the  sacrum,  followed  by 
ankylosis  of  the  sacro- iliac  joints.  The  alae  of  the  sacrum  are  absent 
or  only  imperfectly  developed ;  the  sacrum  is  narrow,  and  has  descended 
deeply  between  the  ilia ;  the  ischial  tuberosities  and  spines  approach. 
The  antero-posterior  diameters  of  the  pelvis  are  normal  or  increased, 
while  the  transverse  are  much  lessened ;  especially  is  the  transverse  of 
the  outlet  reduced.  Kleinwachter  states  that  in  the  cases  hitherto  ob- 
served the  transverse  of  the  inlet  varied  from  7  to  10  centimetres  (2.7 

33 


514  THE  PATHOLOGY  OF  LABOR. 

to  3.9  inches),  and  that  of  the  outlet  from  2.25  to  6  centimetres  (0.8  to 
2.7  inches). 

The  diagnosis  is  made  by  the  narrowed  pubic  arch,  the  parallelism  of 
the  horizontal  pubic  rami  without  any  abrupt  bending  of  these  bones 
which  is  observed  in  the  osteomalacic  pelvis,  and  chiefly  by  the  great 
narrowing  of  the  sacrum.  This  is  a  very  rare  anomaly,  only  nine  cases 
having  been  observed.  In  six  of  the  nine  the  Csesarean  operation  was 
done.  In  two  cases  in  which  the  transverse  diameter  of  the  inlet  was 
8  centimetres  (3.1  inches),  and  that  of  the  outlet  5.25  centimetres  (2 
inches),  delivery  was  effected  by  cephalotripsy,  and  this  is,  therefore,  re- 
garded as  the  limit  of  its  applicability. 

c.  The  kyphotic  transversely-contracted  pelvis.  Kyphosis  (KV<J>UCIS,  ap- 
plied by  Hippocrates  to  a  bowing  or  curving  of  the  spine,  so  that  one 
was  humpbacked)  means  an  abnormal  convex  curvature  of  the  spine. 

The  origin  of  the  kyphotic  pelvis  is  found  in  an  abnormal  posterior  spinal  cur- 
vature, for  a  compensating  curvature  lower  down  results  from  the  former ;  and  in 
order  that  the  pelvis  may  be  affected  by  the  spinal  anomaly,  the  latter  must  be 
situated  in  the  lumbar  vertebrae,  or  in  these  the  sacral  vertebrae  must  be  affected, 
the  one  known  as  lumbo-dorsal,  the  other  is  lumbo-sacral,  kyphosis.  Further, 
the  sacrum  is  pushed  downward  and  backward :  just  as  in  a  pelvic  deformity 
previously  considered  this  bone  is  pressed  downward  and  forward,  lessening  the 
conjugate,  a  rotation  of  the  bone  upon  its  transverse  axis  forward,  so  that  the 
sacral  promontory  is  brought  nearer  the  pubic  joint,  so  now  a  corresponding  rota- 
tion backward  is  claimed  to  occur. 

Barbour  gives  the  following  summary  of  the  peculiarities  of  the  kyphotic  pel- 
vis based  upon  his  examination :  "  The  iliac  crests  are  drawn  out  from  before 
backward;  the  arching  of  the  crests  is  diminished  and  their  sigmoid  curve 
lessened.  The  anterior  superior  spines  are  thrown  apart.  The  pelvis  is  funnel- 
shaped.  The  conjugate  diameter  is  greatly  increased,  while  the  transverse  is 
relatively,  and  sometimes  absolutely,  lessened.  The  linea  terminalis  is  less 
arched  at  the  sides.  In  the  cavity  the  conjugate  is  increased,  but  to  a  less  ex- 
tent than  at  the  brim.  Sacrum  narrowed  transversely  and  elongated  vertically ; 
its  vertical  curvature  is  diminished  throughout,  its  transverse  in  the  upper  por- 
tion of  the  bone.  At  the  outlet  the  conjugate  is  not  usually  altered.  The  trans- 
verse may  be  contracted,  and  that  to  an  extreme  degree.  The  pubic  arch  is 
narrowed." 

The  most  characteristic  anatomical  peculiarity  of  the  kyphotic  pelvis  is  an 
increase  in  the  antero-posterior  diameter  of  the  brim.  The  contraction  in  the 
transverse  diameter  of  the  outlet,  which  is  the  feature  of  obstetric  importance, 
is  not  so  constant. 

Further,  Barbour,  in  opposition  to  the  teaching  of  Breisky,  states  as  the  result 
of  the  study  of  the  preparations  he  has  had  that  there  is  not,  as  a  rule,  a  rota- 
tion of  the  sacrum  upon  a  transverse  axis,  and  that  the  contraction  at  the  outlet 
is  not  related  to  the  elongation  at  the  brim.  He  further  maintains  that  the  con- 
traction at  the  outlet  implies  a  rotation  of  the  innominate  bones ;  and  this  is 
shown  by  the  fact  that  the  approximation  of  the  tuberosities  is  related  to  separa- 
tion of  the  crests. 

The  most  characteristic  indication  of  the  kyphotic  pelvis  is  found  in  the  pres- 
ence of  a  lumbar  kyphosis,  and  next  in  the  peculiar  walk  of  the  subject,  the 
movement  being  as  if  carrying  some  heavy  load  before  her  and  a  constant  effort 
to  avoid  falling.  By  pelvimetry  we  find  the  true  conjugate  increased ;  the  trans- 
verse measurements  of  the  false  pelvis  are  normal,  but  that  between  the  posterior 
iliac  spine  is  lessened. 

The  distinction  just  given  is  the  direct  opposite  of  the  conditions  observed  in 
the  osteomalacic  pelvis,  with  which  this  may  be  confounded,  for  in  that  the 
anterior  transverse  diameters  of  the  false  pelvis  are  lessened,  while  the  distance 
between  the  posterior  iliac  spine  is  increased.  The  pubic  arch  is  narrowed  in 
the  rhachitic  and  also  in  the  osteomalacic  pelvis,  while  no  narrowing  is  present 


ANOMALIES  OF  THE  PELVIS.  515 

in  this.     Besides,  the  first  two  occur  in  persons  whose  history  points  to  one  or  the 
other  disease.     In  such  a  pelvis,  too,  the  promontory  is  quite  accessible. 

Of  course,  the  prognosis  rests  chiefly  upon  the  degree  of  contraction. 
It  is  of  especial  importance  in  this  connection  to  know  the  transverse 
diameter  of  the  outlet.  Further,  it  is  important  to  know  if  "  the  ischial 
tuberosities  move  upon  being  pressed  apart.  Korsch  has  demonstrated 
that  even  in  the  normal  pelvis  the  transverse  of  the  outlet  can  be  thus 
slightly  increased,  this  movement  being  accompanied  by  a  diminution 
in  the  conjugate."1  But  before  this  observation  both  Mattel  and  La- 
borie  had  asserted  that  an  increase  in  the  transverse  diameter  of  the 
outlet  resulted  from  the  wedge-like  pressure  of  the  ftetal  head. 

In  consequence  of  the  lessened  abdominal  capacity  arising  from  a 
lumbar  kyphosis,  the  uterus  may  be  strongly  anteverted,  and,  hence, 
difficulty  in  the  head  entering  the  inlet.  Bnt  the  most  frequent  fact  as 
to  the  position  of  the  child  in  the  abdomen  that  has  been  observed  is 
that  the  fetal  back  is  posterior — that  is,  toward  the  mother's  spine — 
"  probably  in  consequence  of  the  pendulous  abdomen  generally  present, 
the  limitation  of  abdominal  space,  and  the  compensating  lordosis  of  the 
upper  portion  of  the  spinal  column,  through  which  the  anterior  plane 
of  the  fetus  can  be  better  adjusted  to  the  anterior  abdominal  wall." 
This  explains  the  frequency  of  occipito-posterior  positions.  Accord- 
ing to  Barbour,  the  shape  of  the  pelvis  favors  posterior  rotation  of  the 
occiput. 

He  gives  a  table  of  32  cases  of  kyphosis  and  52  labors ;  there  were 
33  recoveries  from  these  52  labors,  but  of  the  32  mothers,  19  ultimately 
died  after  labor.  He  thus  finds  in  his  collection  of  cases  that  there  was 
a  fetal  mortality  of  52  per  cent,  and  a  maternal  mortality  of  36.5  per 
cent.,  according  to  the  number  of  confinements,  or  59.4  per  cent.,  accord- 
ing to  the  number  of  cases  of  kyphosis. 

The  extreme  limit  admitted  by  Barbour  for  the  application  of  forceps 
is  3.25  inches,  and  if  this  diameter  is  less  he  advises  craniotomy.  There 
were  7  cases  of  Csesarean  section,  6  mothers  dying ;  9  cases  ended  spon- 
taneously, and  7  mothers  recovered.  Zweifel  regards  the  prognosis  as 
more  favorable  in  this  than  in  other  pelvic  contractions,  because  the  nar- 
rowing is  at  the  outlet.  But  he  adds  that  Csesarean  section  has  been 
necessary,  and  as  spontaneous  rupture  of  the  uterus  has  occurred,  and 
even  after  the  use  of  the  forceps  death  rapidly  followed,  it  is  advisable 
in  a  given  case  to  keep  this  possibility  in  mind. 

RHACHITIC  KYPHOSIS."  While  th£  changes  in  the  pelvis  caused  by  rickets  are 
in  the  main  directly  opposed  to  those  caused  by  kyphosis,  on  the  other  hand, 
should  kyphosis  result  from  rickets,  the  pelvis  may  present  a  similar  form  to  that 
observed  if  the  kyphosis  has  a  different  etiology.  The  kyphosis,  in  order  to 
change  the  form  of  the  pelvis,  must,  as  in  the  account  of  the  kyphotic  pelvis  just 
given,  concern  the  lumbar  vertebrae.  The  diameters  of  the  outlet  are  lessened, 
and  the  diminution  is  greatest  in  the  antero-posterior. 

The  Third  Class  includes  Pelves  chiefly  Contracted  in  the  Oblique 
Diameter. 

a.  The  ankylotic  obliquely-contracted  pelvis.     Dionis  was  credited  by 

1  Barbour,  op.  cit.  2  Zweifel. 


516 


THE  PATHOLOGY  OF  LABOR. 


Naegele  with  having  first  alluded  to  the  pelvis  contracted  in  an  oblique 
diameter.  Certainly,  this  distinguished  French  accoucheur  does  refer 
to  difficult  labor  caused  by  spinal  deformities,  and  also  to  changes  in 
the  pelvis  caused  by  rhachitis,  but  his  reference  to  the  pelvis  now  to  be 
considered  is  by  no  means  clear. 

The  oblique-oval,  or  Naegele's  basin,  was  first  described  by  Naegele 
in  1839.  It  is  distinguished  by  the  fact  that  one  sacro-iliac  synchon- 
drosis  has  been  ossified,  and,  as  a  consequence,  one-half  of  the  basin 
becomes  narrower. 

The  part  of  the  sacrum  belonging  to  the  ankylosed  side  is  imper- 
fectly developed,  and  its  union  with  the  innominate  bone  is  made  by  a 

FIG.  199. 


OBLIQUELY-DISTORTED  PELVIS,  OB  NAEGELE'S  PELVIS. 

narrow  ledge  of  greatly  condensed  osseous  tissue  instead  of  by  a  broad 
articulating  surface.  There  is  slight  scoliosis  involving  the  lumbar 
vertebra.  In  Kleinwachter's  case  there  was  also  rhachitis.  The  iliac 
bone  of  the  affected  side  is  raised  and  projects  further  back  than  its 
fellow.  The  sciatic  notch  is  lessened  in  consequence  of  the  ischium 
being  pressed  upward  and  inward,  and  the  ischial  tuberosity  and  spine 
approach  the  sacrum. 

The  absence  or  rudimentary  condition  of  the  sacral  wing  upon  the 
affected  side  finds  its  most  rational  explanation  in  the  absence  of  ossifi- 
cation nuclei,  and,  therefore,  the  deformity  may  have  an  intra- uterine 
origin ;  this  was  the  view  favored,  though  not  exclusively,  by  Naegele. 
But  it  is  also  held  that  the  deformity  may  result  from  pathological  con- 
ditions of  the  joint  in  infancy  or  childhood;  in  other  words,  inflamma- 
tion lies  at  the  beginning  of  the  change.  The  theory  of  an  inflammatory 
origin  in  some  cases  after-  birth  does  not  exclude  that  possibly  this 
inflammation  may  begin  in  intra-uterine  life;  if  the  inflammation  occurs 
after  birth,  its  cause  may  be  simply  pressure  of  the  trunk,  which  will 


ANOMALIES  OF  THE  PELVIS.  517 

be  greater  upon  that  side  corresponding  with  an  imperfectly  developed 
sacrum.  It  is  impossible  for  disease  of  one  of  the  sacral  joints  in  adult 
life  to  cause  the  deformity. 

Thomas,1  in  1861,  from  a  study  of  the  50  cases  of  oblique  oval  basin  up  to  that 
time  described,  classified  them  as  to  their  etiology  as  follows  : 

a.  Oblique  pelves  found  in  women  who  during  their  infancy,  or  in  all  cases 
before  the  ankylosis  was  recognized,  had  suffered  from  disease  of  the  pelvic 
bones,  9  cases. 

b.  Oblique  basins  with  fracture  of  the  pubis  on  the  same  side  as  the  ankylosis, 
2  cases. 

c.  Oblique  basins  with  traces  of  periostitis  or  exostosis  of  the  hip-bones,  3  cases. 

d.  Oblique  basins  in  which  there  was  found,  beside  the  ankylosis,  a  coxal 
arthritis  of  the  same  side  or  of  the  opposite  side,  5  cases. 

e.  Oblique  basins  without  any  other  trace  of  disease,  of  which,  nevertheless, 
the  history  was  too  imperfectly  known  to  permit  the  absolute  statement  that  in 
the  women  to  whom  these  pelves  belonged  there  was  nothing  observed,  especially 
in  youth,  indicating  a  morbid  state  of  the  pelvic  bones,  27  cases. 

/.  Oblique  basins  without  visible  traces  of  disease  of  the  pelvic  bones  in  women 
whose  history  was  sufficiently  well  known,  so  that  it  could  be  affirmed  they  had 
never  suffered  from  any  affection  of  the  bones. 

Whatever  or  whenever  the  origin  of  the  deformity,  the  latter  presents 
a  most  characteristic  form  which  is  well  shown  in  the  illustration  that 
has  been  given.  The  pelvic  inlet  is  asymmetrical,  and  presents  the 
form  of  an  obliquely  placed  oval  with  a  point  projecting  to  the  ankylosed 
side.  The  antero-posterior  diameter  is  increased,  but  the  transverse  is 
lessened,  and  there  is  a  continued  lessening  of  this  diameter  through  the 
cavity  and  to  the  outlet. 

Most  of  the  cases  of  obliquely-contracted  pelvis  have  been  diagnosed 
after  death  ;  the  entire  number  of  cases  observed  is  given  as  about  fifty, 
but  probably  this  is  too  small.  Zvveifel  states  that  with  a  great  differ- 
ence between  the  two  sides  of  the  pelvis  the  diagnosis  during  life  cannot 
be  difficult.  Should  there  be  delay  during  labor  in  the  entrance  of  the 
head  into  the  pelvis,  the  possibility  of  this  deformity  will  be  suggested 
if  we  find  it  impossible  to  reach  the  sacral  promontory.  The  limping 
gait  of  the  subject  may  not  be  observed,  but  it  is  important  to  learn 
whether  there  is  any  history  of  inflammation  of  the  joint  in  infancy  or 
childhood,  and  whether  any  evidences  of  suppuration  following  such 
inflammation  can  be  found  in  healed  sinuses.  Freund  claimed  that,  an 
examination  being  made  per  rectum,  the  woman  standing  alternately  on 
one  and  then  on  the  other  foot,  some  movement  would  be  detected  in  an 
unaffected  joint,  while  the  ankylosed  one  would  be  immobile. 

Internal  examination  should  be  made  with  the  half  or  with  the  whole 
hand,  and  thus  the  want  of  correspondence  in  the  position  of  the  ischial 
spines,  the  distortion  of  the  promontory,  and  the  displacement  of  the 
pubic  joint  will  be  learned.  The  most  important  external  measurement 
in  order  to  prove  that  the  basin  is  asymmetrical  is  the  distance  between 
the  trochanter  major  of  one  side  to  the  iliac  crest  of  the  other,  and 
vice  versa. 

Naegele  directed  the  following  measurements  to  be  made : 

1.  From  the  posterior  superior  spine  of  one  side  to  the  anterior  superior  spine 

1  Das  SchrSgverengte  Becken,  quoted  by  Naegele  and  Grenser. 


518  THE  PATHOLOGY  OF  LABOR. 

of  the  other  side — from  the  right  side  behind  to  the  left  side  in  front — normally 
21.22  centimetres. 

2.  From  the  trochanter  major  of  one  side  to  the  posterior  superior  spine  of  the 
other — 22.25  centimetres. 

3.  From  the  middle  of  the  inferior  margin  of  the  pubic  joint  to  the  posterior 
superior  spine  of  each  side — 17.25  centimetres. 

4.  From  the  ischial  tuberosity  of  one  side  to  the  posterior  superior  spine  of  the 
other — 17. 5  centimetres. 

5.  From  the  spinous  process  of  the  last  lumbar  vertebrae  to  the  anterior  supe- 
rior spine  of  each  side — 18  centimetres. 

These  oblique  diameters,  as  Naegele  termed  them,  must  show  a  difference 
between  each  two  corresponding  ones  of  more  than  one  centimetre  in  order  to 
make  the  diagnosis  of  obliquely-contracted  pelvis. 

In  this  pelvis,  if  the  ankylotic  contraction  be  great,  the  passage  of 
the  child  is  necessarily  made  through  that  portion  of  pelvic  space  corre- 
sponding to  the  healthy  side,  for  that  which  belongs  to  the  ankylotic 
side  is  so  contracted  that  no  part  of  the  foetus  can  be  admitted.  The 
space,  then,  that  is  available  is  quite  similar  in  form  to  that  given  by 
the  justo-minor  pelvis ;  and  if  labor  be  possible  the  mechanism  is  the 
same,  the  occiput  descending  first,  as  has  been  described  in  the  course 
of  labor  occurring  in  that  pelvis.  Presentation  of  the  breech  is  very 
unfavorable,  because  of  the  great  difficulty  in,  or  impossibility  of,  the 
passage  of  the  head. 

The  prognosis  as  to  the  mother  of  course  depends  upon  the  degree  of 
the  deformity,  the  vigor  of  labor-forces,  the  size  and  degree  of  resistance 
to  moulding  of  the  foetal  head,  and  the  size  of  the  child;  the  maternal 
mortality  given  by  Litzmann  and  Thomas  is  80  per  cent.  But  this 
high  percentage  is  to  be  attributed  to  the  fact  that  in  most  of  the  cases 
the  deformity  was  not  recognized  soon  enough  for  the  use  of  appropriate 
therapeutic  means,  and  in  some  instances,  according  to  Kleiuwachter, 
the  means  employed  directly  caused  the  death  of  the  mother.  Zweifel, 
too,  regards  Litzmann's  statistics  as  being  too  unfavorable.  He  advises 
the  forceps  if  the  head  enters  the  pelvis,  but  if  this  entrance  be  impos- 
sible the  Caesarean  operation,  especially  as  in  cases  of  such  difficulty 
uterine  rupture  is  liable  to  occur. 

6.  The  coxalgic  obliquely-contracted  pelvis.  This  pelvis  is  similar  to 
that  just  described,  but  there  is  this  remarkable  difference  in  manifesta- 
tion :  While  in  the  Naegele  pelvis  the  arrest  of  development  or  the 
inflammation  of  the  sacro-iliac  joint  affects  the  side  of  the  basin  in  which 
it  occurs,  in  this  deformity  the  coxitis  and  subsequent  ankylosis  are 
upon  the  side  of  the  pelvis  which  remains  comparatively  normal,  and 
the  healthy  side  becomes  misshapen. 

The  pelvis,  represented  in  Fig.  200,  was  taken  from  a  negress  upon  whom  Dr. 
R.  G.  Curtin  performed  Caesarean  section,  and  it  exhibits  very  clearly  the  fact 
of  the  pelvic  deformity  being  manifest  upon  the  healthy  side,  while  that  upon 
which  the  coxitis  occurred  is  normal.  The  history  of  the  usual  development  of 
this  pelvis  is  that  a  child  suffers  from  coxitis  so  severely  that  the  corresponding 
lower  limb — for  example,  let  the  affection  be  upon  the  right  side — becomes  use- 
less, and  the  weight  of  the  body  rests  upon  the  left  femur.  This  pressure  causes 
similar  changes  in  form  in  the  basin  to  those  observed  in  the  Naegele.  The  left 
acetabulum  is  pressed  upward,  and  it  comes  more  in  front ;  the  innominate  line 
is  bent  in  front  at  an  acute  angle,  and  the  left  ilium  is  higher  and  less  inclined ; 
the  left  half  of  the  sacrum  is  narrowed,  so  that  the  entire  bone  loses  its  symmet- 


ANOMALIES  OF  THE  PELVIS. 


519 


rical  form ;  the  left  ischial  tuberosity  and  spine  move  backward  and  outward, 
and  the  pubic  joint  is  placed  opposite  the  right  side. 

There  are  several  modifications  of  the  coxalgic  oblique  basin  according  to  the 
period  in  adolescence  when  the  disease  of  the  joint  began  and  as  to  the  degree  of 
use  permitted  by  the  diseased  limb.  Thus,  the  earlier  in  childhood  the  disease 
occurs  and  the  more  the  limb  is  used,  the  greater  the  deformity.  On  the  other 
hand,  if  the  coxitis  is  first  manifested  after  complete  development  of  the  basin, 
the  obliquity  may  be  completely  absent. 

FIG.  200. 


A  COXALGIC  OBLIQUELY-CONTRACTED  PELVIS  (Mutter  Museum,  College  of  Physicians,  Philadelphia). 

So,  too,  the  obliquity  may  involve  first  one  side,  and  then  it  may  change  to 
the  other.  Zweifel  gives  the  following  illustration :  A  child  has  coxitis  of  the 
right  side,  ending  in  firm  ankylosis,  the  right  lower  limb  being  shortened.  It 
necessarily  limps,  and  the  concussion  in  walking  will  be  greater  than  on  the  left 
side,  this  jar  being  felt  not  only  at  the  hip-joint,  but  also  in  the  corresponding 
sacro-iliac  synchondrosis ;  hence,  ascension  of  the  iliac  bone.  If  now  a  chronic 
inflammation  in  the  sacro-iliac  joint  is  superadded,  the  corresponding  sacral 
wing  will  be  retarded  in  its  growth ;  hence  the  right  half  of  the  pelvis  becomes 
smaller  than  the  left  half,  the  pubic  symphysis  is  pushed  to  the  left,  and  the 
oblique  diameter  of  the  pelvis  from  the  left  anteriorly  to  the  right  is  shortened. 
Suddenly,  however,  all  this  may  be  changed,  so  that  by  muscular  traction  a 
pelvis  presenting  an  opposite  contraction  may  be  developed.  For  if  the  child 
ceases  to  use  the  right  lower  limb,  the  plane  of  support  is  exclusively  given  by 
the  left  femur.  But  it  is  not  necessary  to  follow  the  changes  that  then  result  in 
the  form  of  the  pelvis,  the  diseased  side  furnishing  comparatively  a  normal  con- 
dition of  the  corresponding  side  of  the  pelvis,  and  the  healthy  side  becomes  in 
this  regard  abnormal. 

Paralysis  of  a  lower  limb  or  amputation  of  a  leg  is  rarely  followed 
by  any  great  change  in  the  form  of  the  basin,  because  in  the  great 
majority  of  cases  this  has  attained  complete  development  before  either 
occurs. 

The  coxalgic  pelvis  so  gravely  deformed  as  seriously  to  interfere  with 
labor  is  rarely  seen.  The  recognition  of  the  deformity  will  be  made, 


520  THE  PATHOLOGY  OF  LABOR. 

first,  by  having  a  history  of  coxitis  in  early  life,  and  finding  its  effect 
in  a  useless  abdominal  member,  and  then  by  a  direct  examination  of 
the  pelvis.  In  slight  cases  of  the  deformity  labor  needs  no  assistance, 
while  in  the  ga\ne  ones  labor  and  its  treatment  are  the  same  as  advised 
in  similar  circumstances  in  the  Naegele  pelvis. 

c.  The  scoliotic  obliquely-contracted  pelvis.  This  deformity  arises  from 
a  scoliosis  involving  the  lumbar  vertebra,  there  being  thus  caused  a 
greater  pressure  upon  that  half  of  the  upper  articulating  surface  of  the 
sacrum  corresponding  with  the  side  toward  which  the  spinal  curvature 
occurs.  By  the  connection  of  the  sacrum  with  the  innominate  bone 
this  increased  pressure  is  transmitted  to  the  femur  of  that  side.  But 
the  resistance  of  the  latter  causes  leaning  inward  of  the  parts  adjacent 
to  the  acetabulum,  and  hence  that  side  of  the  pelvis  becomes  greatly 
lessened.  A  scoliosis  of  the  vertebrae  toward  the  right  diminishes  and 
deforms  the  right  half  of  the  pelvis,  while  the  left  is  similarly  affected 
by  a  scoliosis  with  its  curve  directed  to  the  left. 

Should  the  scoliosis  be  limited  to  the  dorsal  vertebra,  a  compensating 
curve  of  the  lumbar  vertebra  may  prevent  any  influence  upon  the  pelvic 
form. 

This  deformity  renders  one  side  of  the  pelvic  canal  useless,  so  far  as 
furnishing  space  for  the  transmission  of  the  child.  The  mechanism  of 
labor  is  that  described  as  occurring  in  the  justo-minor  pelvis,  and  the 
assistance  to  be  given  by  the  obstetrician,  provided  the  contraction  be 
not  so  great  as  to  forbid  the  passage  of  a  living  child,  is  by  forceps, 
remembering,  however,  that  this  instrument  is  not  to  be  used  until  the 
head  has  been  sufficiently  moulded. 

DEFORMITIES  OF  THE  PELVIS  CAUSED  BY  FRACTURES  OR  BY  NEO- 
PLASMS OF  THE  PELVIC  BONES.  Fracture  of  the  horizontal  ramus  of 
one  of  the  pubic  bones  may  result  in  serious  deformity  of  the  pelvis, 
because  of  the  impossibility  of  keeping  the  broken  ends  of  the  bone  in 
apposition  during  healing.  Eugene  de  Saint-Moulin1  narrates  the  case 
of  a  girl  sixteen  years  of  age  who,  while  working  in  a  coal-mine,  was 
injured  by  the  falling  of  a  large  mass  of  coal  upon  the  lower  portion  of 
her  back;  after  several  months  she  recovered  so  that  she  could  walk, 
though  with  some  difficulty,  and  there  was  slight  spinal  deformity. 
Five  years  afterward  she  became  pregnant,  and  the  diameter  of  the 
superior  strait  being  only  three  centimetres  six  millimetres,  the  Caesa- 
rean  operation  was  successfully  done  at  the  end  of  the  pregnancy. 
Seven  years  after  she  was  again  pregnant,  and  at  seven  months  rupture 
of  the  uterus  occurred,  the  tear  being  in  part  of  the  uterine  incision 
made  in  the  previous  operation,  and  the  rupture  ended  fatally.  The 
autopsy  showed  that,  in  addition  to  marked  lumbar  lordosis,  the  second 
sacral  vertebra  was  crushed,  so  that  the  first  was  directly  buried  in  the 
pelvic  cavity,  and  there  was  a  synostosis  between  its  inferior  border  and 
the  superior  border  of  the  third  sacral  vertebra.  The  spondylolisthesis 
had  thus  a  very  rare  origin  in  this  case. 

Various  neoplasms — enchondroma,  sarcoma,  carcinoma,  exostosis, 
fibroma — may,  originating  from  any  part  of  the  internal  surface  of  the 

1  Journal  d'Accouchements,  1885. 


ANOMALIES  OF  THE  PELVIS.  521 

pelvic  bones,  encroach  so  greatly  upon  the  bony  birth-canal  that  the 
Csesarean  section  is  necessary. 

Deventer,  who  was  the  first  obstetrician  to  give  any  clear  exposition  of  pelvic 
deformities,  regarding  the  position  of  the  coccyx  as  sometimes  causing  a  serious 
obstacle  to  labor,  occupied  several  pages  of  his  well-known  work  with  the  sub- 
ject, and  gave  directions  as  to  pushing  the  head  back  and  thus  enlarging  the 
pelvic  outlet.  Since  then  other  obstetricians  have  urged  the.  hindrance  in  labor 
from  sacro-coccygeal  ankylosis.  The  pressure  of  the  child's  head  in  labor  is 
sufficient  to  overcome  the  resistance. 

EFFECT  OF  INCREASED  AND  OF  LESSENED  PELVIC  OBLIQUITY 
IN  PREGNANCY,  AND  IN  LABOR.  If  the  inclination  of  the  pelvis  be 
notably  increased,  a  pregnant  woman  will  especially  sufler  from  pendulous 
abdomen,  and  in  labor  delivery  may  be  impossible  when  she  is  lying 
upon  her  back,  and  therefore  it  will  be  necessary  for  her  to  be  upon  her 
side. 

If  the  inclination  of  the  pelvis  be  much  lessened,  and  labor  rapid, 
rupture  of  the  perineum  is  almost  inevitable.  According  to  Ahlfeld,  if 
with  lessened  pelvic  inclination  there  are  associated  narrow  vagina  and 
a  broad  perineum,  this  rupture  may  be  central,  the  child  delivered 
through  the  rent,  while  the  anal  and  the  vulval  openings  remain  intact. 


CHAPTER    VIII. 

ANOMALIES   OF   THE   FCETUS   AND   OF   THE   FCETAL   APPENDAGES. 

ANOMALIES  of  the  foetus  include  those  of  size,  form,  and  presentation 
— the  last  may  be  complex  instead  of  simple,  or  may  be  abnormal  in 
other  respects — other  foetal  anomalies  may  be  malformations  and  mon- 
strosities, single  or  double.  The  cord  may  be  relatively  or  absolutely 
shortened,  or  it  may  prolapse,  and  the  membranes  may  be  unusually 
resistant. 

ANOMALIES  OF  THE  SIZE  OF  THE  FGETUS.  These  may  be  general 
or  partial,  physiological  or  pathological. 

Great  Size  of  the  Foetus.  This  may  relate  to  the  head  only,  or  the 
body  also.  The  diagnosis  of  great  size  of  the  fostal  head  prior  to  birth 
is  uncertain ;  abdominal  palpation  previous  to,  or  during  labor,  and 
by  touch  finding  the  distance  between  the  anterior  and  the  posterior 
fontanelle  to  be  greater  than  usual,  are  thought  by  some  to  furnish  use- 
ful information.  Could  we  know  the  sex  of  the  child  we  might  be 
assisted  in  the  diagnosis  of  the  size  of  the  head.  In  multiparse  advanced 
in  age  it  is  usual  to  find  that  the  child  if  male  has  a  very  large  head. 
In  primiparse  more  than  thirty  years  of  age  the  children  are  larger  than 
in  young  prirniparse.  Possibly  the  patient's  previous  labors  have  been 
protracted  in  consequence  of  the  great  cranial  development  with  prema- 
ture ossification  of  the  bones  of  the  head,  and  they  all  may  have  ended 
in  the  birth  of  dead  children.  In  case  of  prolonged  pregnancy,  as  a 
rule,  the  development  of  the  foetus,  especially  of  the  head,  is  greater 
than  if  the  labor  occur  at  the  normal  time. 

Blake  takes  the  ground  that  it  would  be  a  very  judicious  rule  of  practice  in 
any  dystocia  caused  by  a  large  and  prematurely  ossified  foetal  cranium  not  to  con- 
sider the  question  of  forceps  delivery.  "  We  may  resort  to  the  perforator  with 
less  than  our  usual  repugnance  to  its  use  if  we  bear  in  mind  the  fact  that  quite  a 
proportion  of  children  born  with  closed  or  partially  closed  fontanelles  and  ossified 
sutures  will,  if  not  early  cut  off  with  symptoms  of  brain  irritation  and  pressure, 
be  epileptic  and  idiotic."1 

Jacobi  states  that  premature  ossification  of  the  sutures  and  fontanelles  occurs 
particularly  with  the  first  child,  and  in  the  milk  of  young  mothers  the  phosphates 
are  predominant  as  compared  with  the  milk  of  mothers  later  in  life.2 

The  induction  of  premature  labor  is  clearly  indicated  in  the  case  of  a 
pregnant  woman  whose  previous  pregnancies  have  ended  in  stillbirths 
from  the  great  cranial  development  of  the  children.  One  of  the  most 
frequent  causes  for  the  application  of  the  forceps  is  the  necessary  dispro- 
portion which  exists  between  the  head  and  the  normal  pelvis ;  if  the 
former  be  unusually  large,  turning  is  not  advisable,  but  in  some  instances 
craniotomy  may  be  necessary. 

i  American  Journal  of  Obstetrics,  vol.  xii.  s  Ibid.,  p.  358. 


ANOMALIES  OF  F(ETUS  AND  POSTAL  APPENDAGES.         523 

Jacquemier  has  said  that  after  spontaneous  or  artificial  delivery  of 
the  head  it  was  thought  by  some  that  the  shoulders  became  too  large  by 
development  of  the  chest,  and  presented  an  obstacle  to  the  escape  of  the 
foatus  so  that  it  was  impossible  for  the  uterus  alone  or  assisted  by  the 
usual  artificial  means  to  expel  it,  at  least  as  promptly  as  required  by  its 
precarious  situation  thus  suspended  between  intra-  and  extra-uterine  life. 
It  is  not,  however,  the  great  volume  of  the  shoulders  so  much  as  that  of 
the  chest  which  causes  the  delay,  conjoined  with  some  degree  of  uterine 
inertia.  When  this  difficulty  is  anticipated  the  practitioner  must  beware 
of  deep  anesthesia,  provided  an  anaesthetic  be  administered,  during  the 
delivery  of  the  head,  lest,  even  if  uterine  inertia  be  not  thereby  invited, 
the  voluntary  expulsive  efforts  of  the  patient  may  fail  when  they  are 
most  needed. 

Difficult  delivery  of  the  shoulder  is  considered  on  pages  306  and  307.  Fracture 
of  the  clavicle  has  occurred  in  some  cases  from  direct  pressure  of  the  obstetri- 
cian's fingers  in  endeavoring  to  extract  the  inferior  shoulder. 

PARTIAL  INCREASE  IN  THE  SIZE  OF  THE  FCETUS.  1.  Hydrocepha- 
lus.  By  this  is  meant  abnormal  accumulation  of  serous  liquid  in  the 
cranial  cavity.  It  is  met  with  once  in  3000  births.  It  has  been  attrib- 
uted to  syphilis,  alcoholism,  cretinism,  and  to  marriages  of  consanguinity. 
The  mothers  were,  in  many  instances,  past  forty  years  of  age,  and  lived 
in  bad  hygienic  conditions.  Poullet1  states  there  are  cases  in  which 
women  have  a  predisposition  of  unknown  nature  to  produce  hydro- 
cephalic  offspring,  and  cites  an  illustration  from  Franck  of  one  who  had 
in  successive  pregnancies  seven  children  with  hydrocephalus,  and  another 
from  Goelis  of  one  who  had  six.  He  also  directs  attention  to  the  investi- 
gations of  Dareste,  who,  in  the  artificial  production  of  monstrosities,  has 
caused  dropsy  of  the  nervous  centres  in  experiments  upon  the  embryo 
of  the  hen. 

In  hydrocephalus  the  cranial  bones  are  usually  much  thinner  than 
normal,  and  more  flexible ;  they  are  flattened,  are  much  more  widely 
separated,  and  the  fontanelles  larger,  and  in  some  cases  the  latter  occupy 
a  greater  extent  than  the  ossified  parts.  In  many  cases  of  hydrocephalic 
heads  there  is  a  supplementary  fontanelle,  known  as  the  fontanelle  of 
Gerdy,  situated  between  the  anterior  and  the  posterior  fontauelles. 

One  of  the  characteristics  of  the  hydrocephalic  head  is  the  marked 
triangular  form  of  the  face,  the  base  of  the  triangle  being  at  the  forehead, 
which  is  broad  and  prominent,  and  presents  a  distinct  suture,  and  the 
sides  of  the  triangle  rapidly  approach,  meeting  at  the  chin. 

The  great  development  of  the  head  interferes  with  the  normal  accom- 
modation of  the  fostus,  and  hence  there  is  a  much  larger  proportion  of 
presentations  of  the  pelvis.2  Poullet  found  in  106  cases  30  in  which 
the  pelvis  and  8  in  which  the  shoulder  presented.  So  far  there  has 
been  no  example  of  face  presentation  in  hydrocephalus. 

If  the  enlargement  be  not  very  great,  spontaneous  delivery  occurs 

1  De  1'  HydrocSphale  Foetaledans  ses  Rapports  avec  la  Grossesse  et  1' Accouchement.  Paris,  1880. 

2  G  riffith  suggests  t  hat  the  hydrocephalic  head  is  more  frequently  in  the  upper  part  of  the  uterus, 
because  the  fluid  it  contains  has  a  less  specific  gravity  than  that  of  the  amnial  liquor.    London 
Obstetrical  Society's  Transactions,  vol.  xxix. 


524  THE  PATHOLOGY  OF  LABOR. 

after  a  more  or  less  difficult  and  tedious  labor :  "  But  in  the  largest 
number  of  published  observations  the  efforts  of  nature  were  entirely 
powerless  to  effect  the  expulsion  of  the  hydropic  head,  and  after  alter- 
natives of  contractions  and  inertia  from  exhaustion  of  the  uterus,  final 
inertia  supervened,  or  uterine  rupture  occurred,  the  woman  dying  unde- 
livered ;  this,  at  least,  is  the  course  of  spontaneous  labor  without  more 
or  less  able  intervention,  when  the  head  was  large." l  In  some  instances, 
however,  delivery  may  occur  by  the  fluid  passing  from  the  interior  to 
the  exterior  of  the  cranium,  or  it  may  become  infiltrated  in  the  connec- 
tive tissue  of  the  neck,  of  the  chest,  and  of  the  abdomen,  thus  producing 
a  general  oedema.  A  still  more  singular  lessening  of  the  size  of  the 
hydrocephalic  head  may  result  from  the  fluid  passing  into  the  pleural 
or  into  the  peritoneal  cavity,  and  then  the  labor  spontaneously  ends.  In 
some  instances  rupture  of  the  head  occurs,  more  frequently  in  presenta- 
tion of  the  pelvis  than  of  the  head,  and  with  the  free  evacuation  of  the 
fluid  the  obstruction  to  labor  ends.  If  the  slow  labor  demands  the 
application  of  the  forceps,  the  introduction  of  the  blades  and  the  locking 
are  difficult,  the  handles  are  wide  apart,  and  efforts  at  traction  usually 
end  in  the  blades  slipping.  It  should  be  added,  however,  that  if  Tar- 
nier's  forceps  is  used,  this  accident  is  much  less  likely  to  occur.  I  have 
with  it  delivered  a  hydrocephalic  head  when  a  Hodge's  instrument  had 
been  unsuccessfully  tried. 

PROGNOSIS.  This  is  most  unfavorable  for  the  child.  The  statistics 
of  Chassainat2  show  that  in  60  cases  of  foetal  hydrocephalus  41  died 
before  or  during  labor,  and  only  19  were  born  alive ;  only  4  of  the  19 
lived  for  several  years.  Poullet  regards  this  result  as  too  favorable, 
stating  that  he  has  been  unable  after  diligent  search  to  find  a  case  in 
which  hydrocephalus  caused  dystocia  and  the  child  lived. 

DIAGNOSIS.  If  there  is  not  an  excess  of  liquor  amnii,  it  may  be 
possible  to  recognize  the  great  disproportion  between  "  the  round  and 
voluminous  tumor  made  by  the  head,  and  the  other  tumor  at  the  oppo- 
site extremity  of  the  fetal  ovoid,  and  which  may  be  distinguished  as  the 
pelvis."  Upon  auscultation  when  the  head  is  below,  contrary  to  that 
which  is  usual  in  head-first  labor,  the  sounds  of  the  foetal  heart  are 
heard  most  distinctly  higher  than  the  umbilicus.  Combining  digital 
examination,  after  labor  has  begun  and  the  membranes  have  ruptured, 
with  abdominal  palpation,  it  has  sometimes  been  possible  to  perceive 
distinct  fluctuation  between  the  touching  finger  and  the  palpating  hand. 
By  vaginal  touch  alone  a  large  surface,  less  rounded  than  the  normal 
foetal  head,  is  felt ;  it  seems  like  the  bag  of  waters  at  first,  but  a  more 
careful  examination  proves  that  its  walls  are  thicker  and  more  resisting 
than  those  of  the  foetal  sac,  and  possibly  the  hair  may  be  felt ;  during 
a  uterine  contraction  instead  of  the  scalp  being  wrinkled  it  remains 
smooth  and  tense ;  it  may  be  difficult  to  recognize  the  fontanelles  or 
sutures,  for  the  membranous  spaces  intervening  between  the  bones  are 
wide,  but  it  will  be  possible  to  touch  one  of  the  cranial  bones  which  will 
usually  be  found  thin  and  quite  yielding,  and  it  is  more  flat  and  has  a 
greater  mobility.  A  macerated  head,  when  the  death  of  the  foetus  has 

i  Poullet,  op.  cit.  z  Quoted  by  Poullet. 


ANOMALIES  OF  FCETUS  AND  FCETAL  APPENDAGES.          525 

occurred  some  time  before,  may  give  similar  increase  of  mobility,  but 
there  is  no  increase  in  the  size  of  the  head  ;  the  bones  override  during  a 
uterine  contraction,  the  sounds  of  the  foetal  heart  cannot  be  heard,  and 
the  mother  has  not  recognized  foetal  movements  for  some  days. 

If  the  diagnosis  is  not  clear  using  one  or  more  fingers  in  the  vaginal 
examination,  the  entire  hand  is  to  be  employed. 

The  diagnosis  of  hydrocephalus  in  head  presentation  is  sometimes 
difficult,  but  the  difficulty  is  still  greater  in  presentation  of  the  pelvis  ; 
in  most  cases  of  the  latter  it  is  not  made  until  after  the  body  is  delivered, 
and  then  a  delay  arises  from  the  difficulty  or  impossibility  of  the  head 
entering  the  inlet.  During  this  unexpected  delay  it  is  not  unusual  for 
the  child  to  die.  Possibly  if  a  finger  be  now  introduced  so  as  to  feel 
the  occipital  bone  it  will  be  found  thinner  and  less  resisting  than  nor- 
mal ;  by  abdominal  palpation  it  will  be  ascertained  that  the  uterus  is 
much  larger  than  it  should  be  after  the  delivery  of  the  body  of  the 
foetus  ;  if  there  be  difficulty  in  disengaging  the  arms,  the  great  distance 
to  which  the  finger  must  be  carried  to  effect  this  disengagement  is  a 
probable  indication  of  a  hydropic  head. 

TREATMENT.  There  is  but  one  thing  essential,  and  that  is,  lessen 
the  size  of  the  head.  Schroder  and  some  others  have  advised  puncture 
by  a  fine  trocar  with  the  forlorn  hope  that  the  child  may  survive, 
although  he  stated  in  1880  that  he  knew  no  instance  in  which  such  sur- 
vival occurred.  The  advantage  of  perforation  is  that  the  finger  can  be 
introduced  into  the  opening,  then  curved  so  as  to  exert  slight  traction, 
thus,  in  some  cases,  speedily  effecting  delivery.  Some  obstetricians  have 
recommended  delivery  by  podalic  version  immediately  after  the  evacua- 
tion of  the  fluid,  but  if  the  uterus  be  retracted  it  may  be  ruptured  dur- 
ing the  operation,  and  most  obstetricians  prefer  delivery  by  the  head ; 
the  extraction  may  be  made  with  the  forceps,  if  the  instrument  does  not 
slip,  or  if  it  does,  with  the  cephalotribe;  Pajot1  suggests  extraction  by 
taking  a  rod  of  wood  two  inches  and  a  half  long,  to  the  middle  of  which 
a  cord  is  attached,  it  is  passed  into  the  cranial  perforation,  which  should 
be  made  through  a  bone  and  not  in  one  of  the  sutures  or  fontanelles, 
given  a  transverse  direction,  and  then  pulling  on  the  cord. 

Perforation  is  advisable,  too,  in  most  cases  if  the  pelvis  presents, 
though  in  some  the  delivery  may  be  effected  by  traction  upon  the 
lower  limbs  conjoined  with  supra-pubic  pressure;  this  traction,  however, 
has,  in  a  few  cases,  torn  the  body  away  from  the  head,  leaving  the  latter 
in  the  uterus,  and  therefore  the  force  thus  exerted  should  never  be  so 
great  as  to  run  this  risk.  Perforation  has  been  made  through  the  pala- 
tine vault,  at  the  occipital  bone,  behind  the  ear,  or  through  a  lateral 
fontanelle. 

The  almost  insuperable  difficulty  in  reaching  the  head  with  an  instrument  led 
Van  Huevel  to  suggest  an  easier  method  of  evacuating  the  dropsical  fluid,  and 
it  has  in  some  cases  been  successfully  employed.  The  spinal  canal  is  opened  as 
near  the  body  of  the  mother  as  possible  by  a  transverse  incision  two  inches  long  ; 
then  a  rubber  sound  with  a  firm  mandarin  is  easily  made  to  pass  through  the 
opening  and  up  to  the  cranium ;  upon  the  withdrawal  of  the  mandarin  the  fluid 

1  According  to  Poullet,  this  method  was  first  suggested  by  Augier  about  the  middle  of  the  last 
century. 


526 


THE  PATHOLOGY  OF  LABOR. 


readily  escapes  through  the  catheter,  and  the  head  lessened  in  size  may  be  read- 
ily withdrawn  by  traction  on  the  body  or  lower  limbs.    (Fig.  201.) 


FIG.  201. 


EVACUATING  FLUID  IN  HYDROCEPHALUS  BY  OPENING  SPINAL  CANAL. 

FIG.  203. 


FIG.  202. 


MENINGOCELE. 


LARGE  SPINA  BIFIDA. 


Sir  James  Simpson,  in  the  case  of  a  woman  who  had  in  her  two  pregnancies 
hydrocephalic  children,  the  delivery  of  each  being  possible  only  by  cranial  per- 
foration, in  her  third  pregnancy  induced  premature  labor,  and  she  gave  birth  to 
a  living  child. 


ANOMALIES  OF  FCETUS  AND  FCETAL  APPENDAGES.          527 

Encephalocele  and  Hydromeningocele.  The  tumor  formed  by  an  eu- 
cephalocele  may  be  hydropic,  though  it  is  not  often  that  the  enlargement 
from  this  cause  is  so  great  as  to  furnish  an  impediment  to  birth,  but  if 
it  should  the  treatment  is  puncture,  but  some  treatment  of  hydromenin- 
gocele  may  be  necessary. 

Increase  in  the  Size  of  the  Body  of  the  Foetus.  The  body  of  the  foetus 
may  be  greatly  increased  in  size  by  hydrothorax, 
ascites,  accumulation  of  urine  in  the  bladder  from 
closure  of  the  uretha,  cystic  degeneration  of  the  kid- 
neys, tumors  of  the  liver  and  of  the  spleen,  fcetal  in- 
clusion, aortic  aneurism,  and  spina  bifida. 

The  foetus  dying  and  air  having  ready  access,  and 
expulsion  being  delayed,  emphysema  may  result  from 
decomposition,  and  the  foetus  be  greatly  swelled. 

Tumors  appearing  more  frequently  at  the  sacrum 
and  coccyx  than  at  the  upper  part  of  the  trunk  may 
interfere  with  labor. 

It  may  be  stated  in  general  that  when  fluid  collec- 
tions, either  in  cysts  or  in  normal  cavities,  cause 
dystocia,  evacuation  by  puncture  is  indicated ;  solid 
tumors  producing  the  same  result  may  be  lessened  by 
knife  or  scissors. 

SINGLE  MONSTERS.  Acardia,  Acephalia,  Anencephalia,  Hemiceplia- 
lia.  An  acardiac  monster  is  described  by  Schroder  as  originating  from 
anastomosis  of  the  vascular  systems  of  twins  contained  in  the  same 
chorion,  consequently  of  the  same  sex,  the  blood-pressure  being  greater 
in  one  than  in  the  other ;  in  the  latter  the  circulation  becomes  too  feeble, 
as  a  consequence  the  heart,  the  lungs,  and  a  greater  or  less  part  of  the 
trunk  atrophy,  and  the  monstrous  foetus  is  nourished  at  the  expense  of 
the  one  which  is  normally  developed.  The  stasis  thus  produced  in  the 
umbilical  vein  which  leaves  it,  may  have  as  its  consequence  considerable 
hypertrophy  and  an  oedematous  tumefaction  of  the  subcutaneous  connec- 
tive tissue.  He  adds  that  the  acephalous  monster  is  born  frequently  by 
the  feet  half  an  hour  or  three  to  twelve  hours  after  the  well-developed 
child.  The  hypertrophy  of  the  trunk  may  render  extraction  necessary, 
and  if  this  hypertrophy  is  very  great  make  it  exceedingly  difficult; 
Mayer  in  such  a  case  had  to  lessen  the  size  of  the  trunk  by  the  perfora- 
tor. In  hemicephalia  or  anencephalia  there  may  be  a  large  collection 
of  serum  in  the  ventricles,  so  that  there  is  hydrocephalus.  Difficulty 
in  labor  may  come  from  the  great  development  of  the  shoulders,  espe- 
cially if  the  head  presents,  for  this  is  so  small,  unless  enlarged  as  just 
mentioned,  the  way  is  not  opened  for  the  descent  of  the  trunk.  Delivery 
by  podalic  version  is  indicated ;  if  version  cannot  be  done,  the  hand 
may  be  applied  to  the  head,  or  the  finger  introduced  into  the  mouth,  or 
the  blunt  hook  used  to  make  traction ;  if  these  means  fail,  the  arms 
should  be  brought  down. 

Double  Monstrosities.  Such  monstrosities  are  found  four  times  oftener 
in  multiparae  than  in  primiparae,  thus  corresponding  with  the  relative 
frequency  of  labors  in  these  two  classes.  In  a  decided  majority  of  cases 
the  labor  ends  spontaneously,  partly  from  the  fact  that  frequently  it  is 


528  THE  PATHOLOGY  OF  LABOR. 

premature,  and  partly  because  the  mother  in  most  instances  has  pre- 
viously given  birth  to  one  or  more  children. 

C.  Veit1  divides  in  three  classes  double  monsters  with  reference  to  their  ob- 
stetric relations. 

I.  Incomplete  double  formation.    The  union  of  the  two  is  very  intimate : 

Diprosopus,  two  faces  (npdcuirov,  the  face) ;  dipygus,  two  pelvic  ends  (^vyy, 

rump). 
Kephalothoracopagus,  double  face,  double  rump  (pagus,  from  irfyvvpi,  to 

unite). 

The  mechanical  difficulty  depends  upon  the  circumference  of  the  double- 
formed  parts.  Frequently  the  forceps,  or  perforation,  will  be  necessary  in  dip- 
rosopus. 

IL  Two  developed  foetuses  are  united  to  a  great  or  less  extent  at  the  upper  or 
at  the  pelvic  part : 
Craniopagus. 
Ischiopagus. 
Pygopagus. 

These  double  formations  lie  in  a  continuous  line  or  can  be  so  placed.     The 
fetuses  pass  through  the  pelvis  without  great  difficulty. 
III.  Both  fetuses  are  united  together  by  their  bodies : 

Thoracopagus,  dicephalus. 

In  these  there  must  be  more  or  less  great  mobility  of  each  body,  or  of  the 
parts  upon  each  other,  in  order  that  delivery  can  be  effected. 

The  diagnosis  of  a  double  monstrosity  will  not  be  made  until  the  labor  be- 
comes protracted,  and  the  obstetrician,  finding  neither  a  narrow  pelvis  nor 
hydrocephalus  to  explain  the  delay,  introduces  his  entire  hand  in  seeking  to  dis- 
cover the  cause. 

FIG.  205. 


DIPROSOPUS. 


In  regard  to  monsters  results  are  as  a  rule  more  favorable  if  the  lower 
part  or  parts  descend  first,  and  therefore,  should  the  diagnosis  be  made 
during  labor,  podalic  version  is  usually  indicated.  So,  too,  podalic  ver- 
sion has  been  successfully  done  after  the  spontaneous  delivery  of  one  of 
the  heads  of  united  twins,  the  feet  of  both  twins  brought  down,  and 
then  the  bodies,  and  the  head  that  was  unborn  delivered. 

Of  course,  the  mother's  life  is  of  the  greater  importance,  and  there- 
fore the  obstetrician  will  have  in  the  case  of  a  monstrosity  less  hesita- 
tion in  resorting  to  mutilating  operations  upon  it.  The  Caesarean 
operation  is  never  indicated  for  the  purpose  of  saving  the  life  of  single 
or  double  monstrosity. 

1  Sammlung  klin.  Vortrage  von  Volkmann. 


ANOMALIES  OF  F(ETUS  AND  FfETAL  APPENDAGES.         529 

FIG.  206.  FIG.  207. 


DERODYMUS. 
Museum  College  of  Physicians,  Philadelphia 


CEPHALO-THORACOPAGUS.    Front  view.    (STERLEY.) 
34 


530 


THE  PATHOLOGY  OF  LABOR. 


There  are  two  instances  of  children  born  with  three  heads,  and  in  one  the 
child  was  born  alive,  and  continued  to  live  three  days,  sucking  and  crying  with 
each  of  the  three  mouths. 

Kirchhof l  describes  a  thoracopagus  found  after  the  death  of  the  mother,  in  a 
tubal  pregnancy. 

FCETAL  ANOMALIES  IN  PLURAL  LABOR.  Interference  of  one 
fostus  with  the  delivery  of  the  other  is  a  rare  complication  of  twin 
labors.  Among  predisposing  causes  Besson2  mentions  the  great  size  of 
the  pelvis,  the  small  size  of  the  fetuses,  and  their  occupying  a  single 
sac ;  and  among  the  determining  causes  the  use  of  ergot,  untimely  rup- 
ture of  the  fretal  sac,  and  other  interferences  with  the  natural  course  of 
labor.  This  interlocking  of  the  foetuses  may  occur  in  every  one  of  the 
different  varieties  of  presentations  observed  in  labor  with  twins.  Delay 
may  be  caused  by  both  heads  presenting  at  the  inlet,  but  this  must  be 
very  rare,  for  Besson  gives  only  one  example.  More  frequently  when 
the  heads  are  first,  one  descends  into  the  pelvis  slightly  in  advance  of  the 
other,  then  the  latter  is  forced  down  so  that  usually  the  neck  of  the 
first  child  is  pressed  upon.  In  some  cases  the  first  head  is  delivered 

FIG.  209. 


o 


SHOWS  HEAD-LOCKING,  BOTH  CHILDREN  PRESENTING  HEAD-FIRST. 

spontaneously  or  by  forceps,  and  then  it  is  impossible  to  effect  delivery 
of  the  trunk,  or  the  arrest  in  labor  may  come  before  this.  The  illustra- 
tion, Fig.  209  (from  Barnes),  shows  very  well  this  form  of  interlocking. 
In  case  the  first  infant  presents  by  the  pelvis  and  the  second  by  the 
head,  the  body  of  the  former  is  delivered,  and  then  the  labor  stops  from 
the  two  heads  entering  the  pelvis  or  coming  to  its  inlet  together.  One 
form  of  this  difficulty  is  -presented  in  the  accompanying  illustration 
(also  from  Barnes).  In  some  cases  the  head  of  the  second  child  is  fixed 


1  Cent.  f.  Gynakol.,  1894. 


2  Pystocie  specielle  dans  les  Accouchements  multiples. 


ANOMALIES  OF  FCETUS  AND  FCETAL  APPENDAGES.         531 

upon  the  thorax  of  the  first.  When  the  heads  are  locked  together  this 
may  not  be,  as  in  the  illustration,  by  the  chins,  but  by  the  occiputs,  or 
by  a  chin  and  occiput,  or  simply  by  one  side  of  each  head. 

When  the  first  child  presents  by  the  head,  the  second  by  the  pelvis, 
the  bag  of  waters  of  the  former  has  descended  so  as  to  interfere  with 
the  transmission  of  the  latter,  and  the  labor  been  delayed  until  the 
obstetrician  ruptured  the  obstacle.  Besson  quotes  a  case  of  this 
difficulty  occurring  in  the  practice  of  Mauriceau.  When  both 
foetuses  present  by  the  pelvis,  difficulties  may  occur  from  the  simul- 
taneous descent  of  the  feet ;  and  in  one  case  of  this  kind,  reported  by 
Armand,  the  midwife  exerted  such  powerful  pulling  that  she  brought 
away  the  trunk  of  each  child,  leaving  the  heads  in  the  uterus.  Schultze 
delivered  a  woman  pregnant  with  twins,  four  feet  and  one  hand  present- 
ing, by  drawing  upon  the  feet  of  the  child  which  was  lowest.  Cazeaux 
gives  a  case  from  Pleissman,  which  was  probably  the  first  example  in 
which  difficult  labor  from  the  interlocking  of  foetuses  was  treated  by 
raising  the  woman's  pelvis  higher  than  her  chest,  a  treatment  which  has 
within  a  few  years  been  successfully  resorted  to  by  Galbraith1 — the 
principle  but  not  the  plan  used. 

"  Pleissman  states  that  on  one  occasion  he  found  the  orifice  plugged  up  by  the 
parts  that  had  become  engaged,  and  which  at  first  sight  appeared  to  him  to  be  a 
quantity  of  hands  and  feet.  A  more  careful  examination  enabled  him  to  distin- 
guish four  inferior  extremities,  which  were  delivered  as  far  as  the  ham  and  one 
arm."  "  At  first,"  he  says,  "  I  was  in  great  perplexity  because  I  could  find  no 
way  of  introducing  my  hand  into  the  womb  for  the  purpose  of  distinguishing 
and  seizing  the  two  feet  belonging  to  each  child,  and  because  all  my  efforts  to 
make  even  one  of  these  extremities  go  back  again  proved  abortive ;  besides 
which,  in  drawing  any  two  of  them,  I  might  confound  them,  and  bring  down 
the  feet  of  two  different  foetuses  at  the  same  time ;  and  lastly,  even  if  I  succeeded 
in  seizing  the  feet  belonging  to  the  same  child,  I  might,  by  drawing  upon  them, 
engage  the  other  parts,  and  thus  augment  the  difficulties.  Being  greatly  embar- 
rassed as  to  the  proper  course,  and  yet  obliged  to  act,  the  employment  of  a  meas- 
ure suggested  by  Hippocrates,  under  different  circumstances,  happily  suggested 
itself;  it  was  to  suspend  the  patient  by  her  feet,  hoping  that  the  heads  and  bodies 
of  the  children  would,  by  their  weight,  draw  one  or  more  of  the  extremities 
toward  the  fundus  of  the  womb,  which  was  still  distended  by  the  waters.  The 
husband  and  brother-in-law  of  the  woman  passed  their  hands  under  her  hams 
and  thus  held  her  suspended,  so  that  only  the  head  and  shoulders  rested  on  the 
bolster.  I  intended,  as  soon  as  I  mounted  on  the  bed,  to  press  back  one  or  more 
of  the  free  extremities  into  the  womb,  but  two  had  already  returned  from  the 
mere  position  of  the  mother,  and  the  other  three  followed  by  the  aid  of  my 
fingers.  Immediately  afterward  I  was  enabled  to  introduce  my  hand  into  the 
uterus,  and  to  withdraw  successively  therefrom  three  children  by  the  feet." 

The  first  child  may  present  by  the  head  and  the  second  be  transverse. 
Jacquemier  has  narrated  the  post-mortem  condition  found  in  a  woman 
pregnant  with  twins  who  died  undelivered  ;  the  head  of  the  first  fretus 
was  in  the  pelvic  cavity,  but  the  neck  of  the  second  was  below  the 
shoulder  of  the  first,  and  formed  a  half-ring  about  its  neck.2 

The  first  child  may  present  by  the  pelvis,  and  the  second  be  trans- 
verse. Here  the  feet  and  trunk  of  the  former  may  pass  the  latter,  and 
then  the  head  is  arrested  by  the  body  which  obstructs  the  inlet. 

1  American  Practitioner,  1880,  and  American  Journal  of  Obstetrics,  1880. 

2  Manuel  des  Accouchements,  tome  ii.  p.  131. 


532  THE  PATHOLOGY  OF  LABOR. 

The  last  variety  given  by  Besson  is  that  in  which  the  first  child  is 
transverse  and  the  second  presents  by  the  pelvis.  An  illustrative  case 
is  quoted  from  Bartscher,  in  which  the  feet  of  the  second  child  were  in 
the  vagina,  but  the  hand  introduced  into  the  vagina  proved  that  the 
first  was  presenting  by  the  shoulder  and  the  second  was  upon  it  a  cheval, 
that  is,  a  lower  limb  had  descended  upon  each  side  of  its  body. 

The  treatment  of  dystocia  from  interlocking  of  twins  is  directed 
first  to  saving  the  mother,  next  to  saving  both,  and  if  this  cannot  be 
done,  to  saving  one  of  the  twins.  The  first  effort  of  the  obstetrician 
should  be  to  unlock  the  head  or  other  parts  causing  the  obstruction. 
This  may  be  done  in  some  cases  by  combined  external  and  internal 
manipulations.  Since  Galbraith's1  success,  certainly  the  knee-chest 
position  should  be  tried.  He  was  called  to  a  case  of  labor  with  twins, 
first  child  with  pelvic  presentation,  and  delivered  except  the  head,  which 
could  not  be  extracted  ;  the  second  child  with  vertex  presentation.  He 
had  the  patient  take  the  knee-chest  position,  while  he  supported  the  life- 
less body  of  the  partly  delivered  child.  On  introducing  his  hand  he 
found  the  obstructing  head  quite  movable,  and  readily  pushed  it  out  of 
the  way ;  In  a  few  minutes  the  head  of  the  first  child  was  brought 
down  and  its  delivery  effected.  If  unlocking  is  impossible — and  it  may 
be,  in  a  case  in  which  both  heads  present — the  next  step  is  to 
apply  forceps  to  the  head  of  the  first  child  and  endeavor  to  deliver  it. 
Barnes  advises  to  have  an  assistant  during  this  effort  apply  his  hand 
and  push  away  the  second  head,  but  this  supposes  a  very  capacious 
pelvis  and  a  mobile  head.  Tarnier  advises,  if  delivery  cannot  be 
effected  by  the  forceps,  and  the  state  of  the  mother  requires  action, 
especially  if  the  child  be  dead,  crainiotomy.  Decapitation  of  the  first 
child  has  been  practised  by  several  obstetricians. 

Eeimann  in  his  paper,2  "  Simultaneous  Entrance  of  Both  Heads  of  Twins  Into 
the  Pelvis,"  mentions,  among  the  number  who  have  performed  decapitation  under 
these  circumstances,  Meigs,  and  Besson  repeats3  the  statement.  It  may  be  a 
matter  of  no  great  consequence,  but  Meigs4  said  expressly  that  he  never  saw  a 
case  of  the  kind,  afterward  stating  that  one  of  his  "  brethren  "  in  Philadelphia 
did  meet  with  the  difficulty  "  a  few  years  since,"  and  decapitated  the  first  child, 
when  the  second  was  easily  delivered. 

Reimann  lays  down  the  rule  that  in  all  cases  "  the  forceps  should  be 
applied  without  delay  to  the  second  head ;  every  other  measure  is  unsuit- 
able and  useless."  This  statement  seem  s  too  absolute. 

Considering  now  those  cases  in  which  the  first  child  presents  by  the 
pelvis  and  the  seccond  by  the  head  (Fig.  210),  Barnes  states  that  the 
first  child  whose  trunk  is  partly  born  encounters  by  far  the  greater 
danger,  and  having  discovered  that  there  is  but  a  faint  or  no  hope  of 
saving  it,  attention  should  be  turned  to  the  best  means  of  securing  the 
second ;  the  wedge  may  be  decomposed  by  detaching  the  head  of  the 
first,  or  craniotomy  be  done.  Decapitation  of  the  first  child,  too,  is  advo- 
cated by  Besson.  Referring  to  the  rule  of  most  obstetricians  to  apply 
the  forceps  to  the  head  of  the  second  child,  a  rule  which  in  this  particu- 

1  Op.  cit.  2  American  Journal  of  Obstetrics,  1877. 

8  Op.  cit.  *  Op.  cit.,  3d  edition,  p.  500. 


ANOMALIES  OF  FCETUS  AND  FCETAL  APPENDAGES. 


533 


lar  variety  of  locking  of  heads  corresponds  with  that  which  Reimaun 
lays  down  for  all  cases,  he  says  that  it  is  irrational.  Either  the  first 
child  is  living  or  it  is  dead.  If  it  is  dead,  why  not  decapitate  in  order 
to  facilitate  the  passage  of  the  second,  and  lessen  the  pressure  which  the 
head  of  the  other  child  and  the  soft  parts  of  the  mother  are  undergoing? 
If  it  is  living,  which  is  very  improbable  after  the  trunk  has  escaped,  is 


SHOWS  HEAD-LOCKING,  FIRST  Cnitto  COMING  FEET-FIRST;    IMP  ACTION  OF  HEADS 

FROM  WEDGING  IN  BRIM. 

D,  Apex  of  wedge.    E  C,  base  of  wedge  which  cannot  enter  brim.    A  B,  line  of  decapitation 
to  decompose  wedge  and  enable  head  of  second  child  to  pass. 

there  any  chance  of  saving  it?  Craniotomy  upon  the  second  infant  is 
to  be  rejected  because  it  destroys  a  life  which  might  be  saved  by  other 
means.  Reimann  admits  decapitation  of  the  first  child  if  the  forceps 
applied  to  the  second  does  not  effect  delivery,  and  if  the  latter  shows 
distinct  signs  of  life.  Now  in  34  cases  collected  by  Besson  in  which 
the  first  child  presented  by  the  pelvis  and  the  second  by  the  head,  there 
were  only  4  in  which  the  former  was  born  living,  and  therefore  because 


534  THE  PATHOLOGY  OF  LABOR 

the  probabilities  of  saving  the  life  of  the  first  are  so  small,  our  efforts 
should  be  chiefly  directed  to  saving  that  of  the  second  child,  and  when 
the  former  presents  an  insuperable  obstacle  to  the  delivery  of  the  latter, 
it  should  be  got  out  of  the  way  as  soon  as  possible. 

Mai-presentation  and  Complex  Presentation.  The  child  presents 
badly,  that  is,  there  is  a  mal-presentation,  when  some  portion  of  it 
descends  first  which  offers  such  disproportion  to  the  pelvic  canal  that 
spontaneous  delivery  is  impossible.  The  most  frequent  mal-presenta- 
tions  are  those  of  the  shoulder ;  that  is,  the  child,  instead  of  being 
longitudinal  in  the  uterus,  and  one  or  the  other  end  of  the  fetal  ovoid 
lying  in  the  lower  uterine  segment,  is  in  a  position  approximating  a 
transverse  line,  and  hence  some  portion  of  the  side  of  the  ovoid  is  in 
relation  with  the  pelvic  inlet ;  but  as,  in  the  course  of  labor,  one  or  the 
other  shoulder  ultimately  takes  this  position  at  the  superior  strait,  the  pre- 
sentation is  called  by  this  name.  In  addition  to  shoulder  presentations, 
there  may  be,  when  the  head  comes  first,  a  latero-flexion  of  the  head 
upon  the  trunk,  and  hence  the  side  of  the  head  or  of  the  face  for  a 
time  present.  Should  this  inclined  lateral  position  of  the  head  occur, 
nature,  in  almost  all  cases,  rectifies  the  error,  and  the  position  becomes 
normal. 

Dr.  Hodge  has  narrated  the  case  of  a  primipara,  to  whom  he  was  called  after 
she  had  been  in  labor  five  days,  first  under  the  care  of  a  midwife,  and  then 
under  that  of  physicians,  and  who  had  been  given  ergot  freely ;  he  found  the 
superior  strait  "  completely  occupied  by  the  head  of  the  child,  but  an  accurate 
diagnosis  could  not  be  made,  owing  to  bloody  tumors  and  infiltrations  in  the 
presenting  part.  The  blades  of  the  forceps  were  carefully  passed  on  the  sides  of 
the  pelvis  to  the  superior  strait,  and,  without  difficulty,  a  firm  grasp  was  made 
upon  the  child's  head,  which,  however,  was  found  perfectly  immovable.  Crani- 
otomy  being  now  determined  on,  the  head  was  punctured,  the  forceps,  which  had 
not  been  removed,  were  now  used  as  compressors,  their  handles  being  approxi- 
mated by  means  of  a  strong  fillet ;  the  head  yielded  to  this  compression,  and  was 
gradually  brought  down  and  delivered  externally.  It  was  now  found  that  it  had 
been  originally  a  presentation  of  the  right  side  of  the  head,  and  that  one  blade 
of  the  forceps  was  over  the  face,  and  the  other  over  the  occiput ;  so  that  the  long 
diameter  of  the  head  had  been,  by  means  of  the  forceps,  so  diminished  as  to 
allow  the  transit  of  the  head  through  the  outlet  of  the  pelvis,  with  the  face 
toward  one  ischium  and  the  occiput  toward  the  opposite.  The  patient  recovered 
without  any  special  difficulty." 

The  case  just  narrated  illustrates  some  of  the  evil  effects  of  ergot ;  for,  had  it 
not  been  given,  the  mal-presentation  would  almost  certainly  have  been  corrected 
by  nature,  and  the  labor  probably  terminated  spontaneously  with  the  birth  of  a 
living  child.  Nevertheless,  in  case  the  lateral  inclination  of  the  head  persists, 
the  indication  is  plain,  as  urged  by  Dr.  Hodge,  to  rectify  it  by  manual  means  ; 
but  in  some  cases,  version  or  the  forceps  will  be  indicated,  with  a  final  resort,  as 
in  the  instance  given  by  Dr.  Hodge,  to  craniotomy. 

The  management  of  shoulder  presentations  will  be  considered  in 
"  Obstetric  Operations." 

Complex  or  complicated  presentations  are  those  in  which  two  or  more 
unrelated  parts  of  the  foetus — as,  for  example,  the  head  and  a  foot  or  a 
hand — descend.  It  is  convenient,  also,  to  consider  in  this  connection 
prolapse  of  the  cord ;  that  is,  a  presentation  of  the  cord  with  presenta- 
tion of  some  part  of  the  foetal  ovoid,  for  the  same  causes  which  usually 
produce  prolapse  of  members  are  also  in  general  those  of  a  similar 
accident  to  the  cord. 


ANOMALIES  OF  FfETUS  AND  FCETAL  APPENDAGES.          535 

As  an  illustration  of  a  complex  presentation,  the  following  case  from  La  Motte 
is  of  interest.  On  the  27th  of  October,  1711,  he  was  called  to  the  wife  of  a  car- 
penter at  Montebourg,  who  had  been  in  labor  since  the  preceding  day,  and 
whose  child  occupied  such  a  position  that  the  sage-femme  could  not  explain  it. 
He  found  the  woman  very  much  exhausted,  and,  upon  touching,  he  distinguished 
two  hands,  the  head,  a  foot,  and  the  cord,  the  last  being  cold  and  without  pulsa- 
tion. He  introduced  his  hand,  pushing  the  head  away,  and  carried  it  to  the 
fundus  of  the  uterus,  where  he  found  the  second  foot,  which  he  drew  into  the 
passage,  in  order  to  have  the  two  feet  together ;  as  he  drew  the  feet  out  the  arm 
ascended,  thus  leaving  the  passage  free,  and  in  fifteen  minutes  the  woman  was 
delivered. 

Frequency  and  Causes  of  Prolapse  of  Members.  Depaul  found  in 
16,613  labors  163  in  which  there  was  prolapse  of  the  members  alone  or 
with  the  umbilical  cord ;  the  proportion  is,  then,  1  to  102.  The  upper 
limbs  more  frequently  prolapse  than  the  lower.  In  some  cases  a  hand 
or  the  arm  may  descend  by  the  side  of  the  head ;  in  others  a  hand  is  on 
each  side  of  the  head,  or  a  hand  or  arm  descends  with  the  pelvis. 
These  complex  presentations  occur  more  frequently  when  the  vertex  or 
face,  rather  than  the  pelvis,  presents.  In  some  cases  a  foot  has  de- 
scended with  the  shoulder,  but  the  descent  of  a  hand  or  arm  when  the 
shoulder  presents  does  not  complicate  the  presentation  any  more  than 
the  descent  of  a  foot  complicates  that  of  the  pelvis,  since  in  each  case 
the  prolapsed  member  belongs  to  the  part  with  which  it  descends. 
Madame  Lachapelle,  and  all  authors  who  have  written  upon  the  subject 
since,  says  Depaul,  have  admitted  as  predisposing  or  occasional  causes 
the  small  size  of  the  foetus,  the  abundance  of  the  amnial  liquor,  its 
rapid  discharge,  oblique  presentation  of  the  foetus — when,  for  example, 
instead  of  being  directed  in  the  middle  of  the  superior  strait,  it  is  rather 
directed  obliquely  toward  one  of  the  sides  of  the  circumference  of  the 
strait — and,  finally,  vices  of  conformation  of  the  pelvis.  Charpentier 
gives,  in  addition,  rupture  of  the  membranes  when  the  woman  is  stand- 
ing, and  unskilful  or  untimely  attempts  to  perform  version. 

Diagnosis.  We  have  not  only  to  recognize  the  fact  that  the  presenta- 
tion is  complicated,  but  also  the  cause  of  the  complication  ;  in  other 
words,  know  that  a  member  has  prolapsed,  and  what  that  member  is. 
The  diagnosis  before  rupture  of  the  membranes  is  usually  difficult,  and 
may  be  impossible.  Perhaps  a  member  may  be  found  near  the  head, 
and  then  the  former  may  be  pressed  against  the  latter,  so  that  an  exam- 
ination will  determine  whether  it  is  a  hand  or  foot.  In  case  the  head 
or  other  presenting  part  of  the  foetus  is  too  high  for  this  to  be  done, 
Depaul  suggests  pressing  the  member  against  the  pelvic  wall,  and  thus 
fixing  it  momentarily  for  examination.  Of  course,  the  probabilities  are 
that  a  member  found  near  the  head  is  a  hand.  After  the  rupture  of 
the  membranes  the  diagnosis  is  generally  easy.  Sometimes2  it  is  a  hand 
that  is  applied  upon  one  of  the  sides  of  the  head,  in  front  or  behind, 
but  almost  always  resting  upon  one  of  the  parietal  bones,  and  in  others 
it  descends  lower  than  the  head,  and  is  then  readily  distinguished.  The 
forearm  may  be  upon  the  side  of  the  head,  as  if  the  child  were  resting 
on  it.  If  the  pelvis  presents,  of  course  we  know  that  the  prolapsed 

1  Observation  CCXCII.  a  Depaul. 


536 


THE  PATHOLOGY  OF  LABOR. 


member  must  be  a  hand.  In  some  cases  this  has  descended  into  the 
vagina,  and  even  projects  from  the  vulva ;  then  there  is  no  difficulty  in 
recognizing  what  this  member  is,  but  there  may  be  in  deciding  with 
what  presentation  it  is  associated,  for  it  is  not  uncommon  at  once  to 
conclude  from  the  hand  being  in  this  position  that  there  is  a  shoulder 
presentation  ;  but  to  avoid  error  the  practitioner  should  always  follow 
up  the  member  until  he  reaches  the  presenting  part.  So,  too,  if  a  foot 
be  found  in  the  vagina  the  conclusion  that  the  pelvis  presents  is  not  a 
necessary  one,  for  the  former  may  have  descended  by  the  side  of  some 

FIG.  211. 


HAND  PROLAPSED  BY  THE  SIDE  OF  THE  HEAD. 

other  presenting  part.  A  foot  seldom  descends  low  in  the  vagina,  and, 
being  larger,  delays  the  descent  of  the  presenting  part  much  more  than 
a  hand  does. 

TREATMENT.  In  very  many  cases  when  a  hand  or  foot  is  at  the 
side  of  the  fetal  head  before  the  rupture  of  the  waters  it  is,  as  it  were, 
pushed  up  by  the  descending  head,  or  at  least  the  former  is  crowded 
out  of  the  pelvic  inlet  by  the  entrance  of  the  latter.  Or,  again,  if  the 
prolapse  be  slight  and  space  be  sufficient,  the  head  comes  down,  bring- 
ing the  prolapsed  member  with  it.  If  descent  of  one  or  more  members 
be  ascertained  .before  the  rupture  of  the  membranes,  the  patient  should 
lie  down,  and  other  precautions  be  taken  to  preserve  them  entire 
until  the  os  uteri  is  completely  dilated.  If  the  prolapsed  member  in- 


ANOMALIES  OF  FCETUS  AND  FCETAL  APPENDAGES. 


537 


terferes  with  the  entrance  of  the  head  into  the  pelvis,  it  should  be 
replaced  by  the  hand  introduced  into  the  vagina,  after  which  it  may 
be  advisable  to  use  forceps,  or  if  the  contractions  are  vigorous  it  is 
possible  that  the  entrance  of  the  head  into  the  pelvis,  when  the  obstruc- 
tion is  pushed  aside,  takes  place  readily,  and  its  rapid  descent  will  render 
artificial  delivery  unnecessary.  So,  too,  in  some  cases,  especially  in  one 
like  La  Motte's,  podalic  version  is  indicated.  If  reduction  of  a  pro- 
lapsed member  or  members  fail  while  the  patient  is  recumbent,  an 
attempt  may  be  made  when  she  is  in  the  knee-chest  position. 


FIG.  212. 


FIG.  213. 


DORSAL  DISPLACEMENT  OF  THE 
ARM. 


DORSAL  DISPLACEMENT  OF  THE  ARM  IN  FOOTLING 
PRESENTATION. 


DORSAL  DISPLACEMENT  OF  THE  ARM.1  This  has  occurred  in  vertex 
as  well  as  in  pelvic  presentations.  In  the  former  variety  Sir  James 
Simpson,  who  first  described  the  displacement,  advised  bringing  the  arm 
down,  thus  making  a  complex  presentation,  that  of  the  hand  and  head. 

The  following  is  an  extract  from  a  lecture  upon  La  Motte,  given  by  me  more 
than  three  years  ago,  and  the  criticism  made  by  this  great  practical  obstretrician 
upon  Mauriceau's  advice  is  of  interest  in  connection  with  the  observation  of  Sir 
James  Y.  Simpson :  In  case  the  hand  descended  with  the  head,  if  the  labor  was 
well  advanced,  and  could  end  without  help,  La  Motte's  rule  was  no  interference ; 


1  Illustrative  cases  of  this  anomaly  will  be  found  in  Dr.  Alexander  R.  Simpson's  Contributions 
to  Obstetrics  and  Gynecology.  and  in  a  paper  by  Dr.  Freeland  Harbour,  Edinburgh  Obstetrical 
Society's  Transactions,  vol.  xii. 


538  THE  PATHOLOGY  OF  LABOR. 

he  absolutely  rejected  any  attempt  to  restore  the  arm,  believing  it  futile  and 
injurious ;  if  necessary,  he  performed  podalic  version.  He  quoted  Mauriceau 
as  stating  that  in  a  case  of  this  kind,  "  I  reduced  the  arm  behind  the  head,"  and 
criticised  it  as  follows :  "  It  is  not  necessary  to  be  a  good  accoucheur  to  see  that 
a  woman  could  not  be  delivered  without  the  arm  thus  reduced  being  twisted  and 
broken,"  etc.  Of  course,  the  so-called  dorsal  displacement  of  the  arm  would 
inevitably  result.  It  is  remarkable  that  Simpson  did  not  mention  Mauriceau's 
advice,  and  La  Motte's  criticism. 

Playfair  thinks  it  better  to  perform  podalic  version,  and  has  done  it 
successfully  after  having  failed  to  deliver  with  the  forceps.  If  the  dis- 
placement occurs  in  head-last  delivery,  Barnes  advises  rotating  the  child 
in  the  opposite  direction  to  that  rotation  which  he  believes  caused  the 
difficulty.  "By  rotating  the  child  back  in  the  contrary  direction,  so  as 
to  restore  the  original  position,  you  may  possibly  liberate  the  arm.  At 
any  rate,  you  will  render  more  easy  the  further  proceeding  that  may  be 
necessary.  You  carry  the  trunk  well  backward,  so  as  to  give  room  to 
pass  your  forefinger  in  between  the  symphysis  ptibis  and  the  child's 
shoulder ;  and  hooking  on  the  elbow  draw  this  downward,  and  then 
forward.  It  may  be  useful,  as  a  preliminary  step,  to  gain  room  by  first 
liberating  the  other  arm."1  Barnes  further  states  that  if  the  arm  cannot 
be  liberated,  craniotomy  may  be  necessary. 

ANOMALIES  OF  THE  CORD.  Presentation  and  Prolapse.  When 
the  cord  toward  the  end  of  pregnancy  is  in  the  vicinity  of  the  os  uteri, 
or  descends  at  the  beginning  of  labor,  or  only  during  the  period  of 
dilatation,  between  the  presenting  part  and  the  membranes,  there  is 
said  to  be  a  presentation  of  the  cord ;  the  term  prolapse  is  applied  to 
the  descent  occurring  after  rupture  of  the  membranes,  the  prolapse 
being  complete  if  the  cord  protrudes  from,  but  incomplete  if  remaining 
within,  the  vagina. 

FREQUENCY  AND  CAUSES.  Churchill's  statistics  show  that  prolapse 
of  the  cord  occurred  in  British,  French,  and  German  practice  once  in 
23 1J  cases.  In  the  Dublin  Lying-in  Hospital,  in  50,061  cases  it  hap- 
pened 304  times,  or  1  in  168.  Charpentier  gives  the  proportion  of 
1  in  227. 

Naegele,  in  explaining  the  accident,  attributed  great  importance  to 
the  lower  uterine  segment  not  being  completely  occupied  by  the  fetal 
part ;  if  this  application  be  perfect,  the  cord  is  retained  in  the  womb  by 
the  same  cause  which  prevents  the  flow  of  all  the  amnial  liquor  and 
only  that  which  is  between  the  head  and  membranes  is  discharged. 
The  accident  is  nearly  four  times  more  frequent  in  multipart  than  in 
primiparse.  Among  other  causes  usually  given  are  :  excess  of  the  am- 
nial liquor,  premature  rupture  of  the  sac,  smallness  of  the  fetus,  face, 
shoulder,  and  pelvic  presentations,2  great  length  and  weight  of  the 
cord,  its  marginal  attachment,  the  placenta,  being  situated  in  the  lower 
portion  of  the  uterus,  oblique  position  of  the  uterus,  pelvic  deformity, 
and  prolapse  of  one  of  the  foetal  members. 

DIAGNOSIS.  The  recognition  of  the  cord  being  by  the  side  of  the 
presenting  part  may  be  difficult  in  the  early  stage  of  dilatation  when 

1  Obstetric  Operations. 

2  Massman,  quoted  by  Winckel,  estimated  the  frequency,  in  head  presentations  at  1  in  150 ;  in 
breech  presentations,  1  in  21,  and  in  shoulder  presentations,  1  in  12. 


ANOMALIES  OF  FCETUS  AND  FCETAL  APPENDAGES.          539 

the  membranes  are  entire;  if  the  cord  can  be  readily  touched  during 
the  interval  of  a  uterine  contraction,  its  characteristics  may  usually  be 
determined  ;  it  has  not  the  size,  shape,  or  consistence  of  foot  or  hand, 
and  beside,  it  is  not  suddenly  withdrawn  as  a  member  often  is  when 
touched  ;  possibly  by  pressing  it  against  a  resisting  part  pulsation  may 
be  recognized. 

FIG.  214. 


THE  FUNIS  PROLAPSED  BY  THE  SIDE  OF  THE  HEAD. 

After  the  rupture  of  the  membranes,  if  the  cord  has  escaped  from 
the  os  uteri,  diagnosis  is  easy,  especially  if  the  pulsations  can  be  felt. 

The  absence  of  pulsation  in  the  cord  does  not  necessarily  indicate'that  the 
foetus  is  dead,  for  it  may  be  only  temporary  ;  Charpentier  delivered  a  living  child 
by  podalic  version  ten  minutes  after  no  beating  in  the  cord  could  be  felt.  On 
the  other  hand,  as  observed  by  Naegele,  very  often  the  pressure  need  be  for  only 
a  few  minutes  to  kill  the  foetus.  It  is  better,  in  a  doubtful  case,  to  listen  for  the 
sounds  of  the  fcetal  heart. 

PROGNOSIS.  The  accident  does  not  affect  the  mother,  but  is  very 
dangerous  to  the  child.  Engelmanu  states  that  of  365  cases  of  pro- 
lapse 171  of  the  children,  47.7  per  cent.,  were  saved ;  in  foot  presen- 
tations 71  per  cent,  of  the  children  were  saved ;  in  pelvic,  40,  and  in 
vertex,  36.7.  Hecker  had  a  mortality  of  43  per  cent,  in  head  presen- 
tations, and  in  pelvic  17  per  cent.  ;  including  all  cases  the  mortality 


540  THE  PATHOLOGY  OF  LABOR. 

was  37.6  per  cent.  The  statistics  of  Scanzoni  gave  a  mortality  of  55 
per  cent.,  and  those  of  Churchill  53  per  cent. 

TREATMENT.  Formerly  it  was  thought  the  chief  danger  to  the 
child  occurred  from  the  cord  becoming  cold  in  case  of  complete  pro- 
lapse— Velpeau,  indeed,  attributed  the  danger  partly  to  this — and  hence 
the  advice  was  given  to  restore  it  to  the  vagina  or  to  have  it  wrapped  in 
warm  cloths.  Some  have  held  that  the  arteries  only  were  compressed, 
and  hence  the  danger  was  from  plethora,  while  others  thought  the  com- 
pression affected  the  vein  exclusively,  and  therefore  the  child  was  auasmic. 
But  partial  compression  is  rendered  impossible  by  the  arrangement  of 
the  vessels.  It  is  easy  to  understand  that  compression  of  the  umbilical 
cord  in  suppressing  hamatosis  causes  asphyxia  in  the  same  manner  as 
during  extra-uterine  life ;  suffocation,  strangulation,  or  pulmonary  em- 
bolism determines  death  in  suppressing  respiration. 

Recognizing  the  danger  of  death,  we  endeavor  to  avert  it  by  prevent- 
ing pressure  upon  the  cord.  If  presentation  of  the  cord  be  recognized 
in  the  first  stage  of  labor,  the  woman  should  be  lying  down,  and  great 
care  taken  to  preserve  the  bag  of  waters  unruptured  until  this  stage  is 
completed. 

After  the  rupture  of  the  membranes  if  the  cord  prolapses  in  front 
of  the  child's  head,  and  thus  the  life  of  the  foetus  be  endangered  by 
pressure  upon  it,  the  advice  given  by  Smellie  still  remains  the  best. 
He  said :  u  If  the  navel-string  comes  down  by  the  child's  head,  and 
the  pulsation  is  felt  in  the  arteries,  there  is  a  necessity  for  turning 
without  loss  of  time ;  for,  unless  the  head  advances  first  and  the  de- 
livery is  quick,  the  circulation  in  the  vessels  will  be  entirely  obstructed, 
and  the  child  consequently  perish.  If  the  head  is  low  in  the  pelvis, 
the  forceps  may  be  successfully  used."2  McClintock,  in  a  note  upon 
this  passage,  has  stated  that  of  all  modes  of  treatment  recommended, 
the  most  successful,  as  regards  the  child,  is  turning.  "  Thus  of  sixty- 
four  cases,  in  the  practice  of  La  Motte,  Mauriceau,  Lachapelle,  Boivin, 
Giffard,  and  McClintock,  when  turning  was  resorted  to  solely  on 
account  of  the  funis  presenting,  fifty-two  of  the  children  were  born 
alive." 

It  happens  in  some  cases  that  after  the  membranes  have  ruptured, 
and  the  cord  prolapses  so  as  to  be  subjected  to  pressure,  the  head  is 
expelled  so  rapidly  there  is  no  necessity  for  applying  the  forceps,  the 
cord  being  compressed  for  so  short  a  time  that  there  is  no  risk  to  the 
child. 

Prior  to  the  rupture  of  the  membranes  turning  is  not  indicated  if  the 
cord  presents,  for  we  do  not  know  that  after  the  discharge  of  the  amnial 
liquor  it  will  certainly  prolapse  so  as  to  suffer  compression. 

REPLACEMENT  OF  THE  COED.  Neither  turning  nor  the  forceps 
being  employed,  we  may  endeavor  to,  partially  at  least,  protect  the  cord 
from  pressure  by  putting  it  in  that  part  of  the  pelvis  where  the  most 
room  is  found,  and  that  will  be  opposite  one  or  the  other  sacro-iliac 
joints  according  to  the  position  of  the  head.  But  it  is  better  in  most 
cases  to  replace  the  cord^  and  this  reposition  may  be  manual,  instru- 

1  Depaul.  2  Op.  cit. 


ANOMALIES  OF  FCETUS  AND  FCETAL  APPENDAGES.          541 

mental,  or  postural.  Mauriceau  directed  that  an  effort  should  be  made 
to  carry  the  cord  by  the  fingers  of  one  hand  behind  the  head,  and  keep 
it  there  until  the  latter  had  descended,  so  as  to  prevent  its  prolapsing 
again  ;  he  added  that  a  compress  might  be  placed  between  the  head  and 
the  uterus,  to  sustain  the  cord  after  it  was  replaced.  For  Mauriceau's 
compress  other  obstetricians  substituted  a  sponge,  and  still  others  sought 
to  put  the  cord  around  one  of  the  foatal  members.  Dr.  William  Harris, 
of  Philadelphia,  in  a  presentation  of  the  breech,  returned  the  cord  over 
the  knee,  and  the  child  was  saved.1  Boer  thought  so  unfavorably  of 
manual  reposition  because  of  the  fact  that  generally  the  cord  prolapsed 
again  and  again  after  repeated  replacement,  that  he  compared  it  to  the 
task  of  the  .Dana'ides.2 

In  consequence  of  the  liability  to  prolapse  again  after  manual  replacement, 
various  repositors,  that  are  designed  not  only  to  facilitate  the  replacement,  but 
also  to  prevent  the  recurrence  of  the  accident,  have  been  devised.  A  simple  and 
long-known  method  is  to  attach  a  piece  of  whalebone,  or  an  elastic  bougie  or 
catheter,  to  a  small  bag  or  purse,  into  which  the  cord  may  be  placed,  and  then 
be  restored.  As  soon  as  the  head  descends,  the  whalebone  or  bougie  may  be 
safely  withdrawn.3  A  repositor  may  be  improvised  of  an  ordinary  rubber 
catheter  and  stylet,  with  a  piece  of  tape  or  string.  A  loop  of  the  tape  or  string 
is  passed  into  the  eye  of  the  catheter,  and  the  stylet  then  introduced  so  that  it 
holds  the  loop ;  the  cord  is  fastened  by  the  free  ends  of  the  tape,  and  by  the 
catheter  carried  into  the  uterus  as  far  as  desirable,  and  the  stylet  withdrawn. 
Charpentier  speaks  favorably  of  the  following  method  used  by  him  successfully 
in  one  case :  "  The  cord  is  encircled  by  a  loop  of  silk,  and  the  ends  tied  so  that 
the  cord  will  be  firmly  held  but  not  compressed ;  the  ends  are  now  firmly 
fastened  around  the  end  of  an  olive-shaped  elastic  or  wax  bougie ;  the  cord  is 
now  carried  within  the  uterus  until  the  lower  end  of  the  bougie  is  at  the  os.  The 
bougie  is  left  in  the  uterus,  there  is  no  tendency  to  recurrence  of  the  prolapse, 
and  the  instrument  excites  uterine  contractions,  and  thus  hastens,  which  is 
always  desirable,  the  termination  of  the  labor." 

Nearly  two  hundred  years  ago  a  famous  Holland  obstetrician,  Deventer, 
advised  the  position  on  the  knees  and  elbows  in  the  treatment  of  prolapse  of  the 
umbilical  cord :  "  The  advantages  of  this  position  have  been  shown  in  later 
years,  especially  by  Ritgen,  Kiestra,  Thomas,  and  Theopold."4  Winckel  states 
that  he  has  never  used  the  knee-chest  position,  and  has  never  failed  to  replace 
the  cord.  This  position,  if  maintained  for  some  time,  is  quite  wearisome,  and 
certainly  causes  the  uterine  force  to  act  at  a  great  disadvantage.  Deventer  also 
advised  a  lateral  position  in  the  treatment  of  prolapse  of  the  cord ;  and  Galabin 
states  that  if  the  patient  cannot  be  readily  induced  to  adopt  the  knee-elbow 
position,  the  semi-prone  position  may  be  used  from  the  first  with  almost  as  much 
advantage. 

Even  when  the  pulsations  in  the  cord  are  feeble  and  separated  by 
long  intervals,  hope  of  saving  the  child  should  not  be  abandoned ;  the 
less  near  the  end  of  pregnancy  the'  longer  the  child  survives  interference 
with  the  circulation.  But  when  no  pulsation  has  been  discovered  for 
fifteen  minutes,  examinations  being  made  in  the  intervals  of  contractions, 
it  may  be  concluded  the  fo3tus  is  dead,  and  the  delivery  conducted  with- 
out reference  to  its  interests. 

SHOETNESS  OF  THE  CORD.  Brevity  of  the  cord  may  be  absolute  or 
accidental,  the  latter  resulting  from  circulars  around  the  body,  or  mem- 

1  Hodge,  op.  cit. 

2  Depaul  used  the  same  apt  comparison.    Recently  an  able  and  distinguished  writer  deserts  the 
Dana'ides  and  seeks  Sisyphus.    No  one  has  yet  called  upon  Hercules,  or  upon  Briareus. 

3  Hodge.  4  Schroder. 


542  THE  PATHOLOGY  OF  LABOR. 

bers.  While  examples  of  either  form  are  rare,  so  rare  that  a  few  obste- 
tricians have  doubted  the  existence  of  this  anomaly,  yet  instances  are 
not  wanting  to  prove  the  fact,  e.  g.,  Rigby  saw  a  case  in  which  the 
cord  was  only  two  inches ;  Werner,  less  than  four  inches ;  Malgouyre, 
a  little  more  than  two  inches.  Of  course,  the  site  of  placental  attach- 
ment and  the  place  of  insertion  of  the  cord  must  be  considered  in  the 
question  of  shortness;  and  thus  the  cord  must  be  longer  to  permit  the 
delivery  of  the  child  if  the  placenta  is  at  the  fundus  than  in  the  lower 
portion  of  the  womb,  longer  too,  if  the  insertion  of  the  cord  be  central 
than  if  it  be  at  the  inferior  margin  of  the  placenta.  Negrier  states  that 
the  genital  canal  at  the  time  of  foetal  expulsion  is  22  centimetres  (8.69 
inches)  and,  therefore,  Lamare  asserts  that  the  cord  becomes  too  short 
if  less  than  25  centimetres  (9.87  inches). 

The  diagnosis  of  brevity  of  the  cord  is  from  lingering  labor,  not 
otherwise  explained,  slight  flow  of  blood  immediately  after  a  contraction, 
depression  of  the  uterus  at  the  place  of  placental  attachment  during  a 
contraction,  and  great  recession  of  the  presenting  part  when  the  con- 
traction ceases.  King,  who  has  given  much  study  to  the  subject  and 
written  several  valuable  articles  upon  it,  regards  as  an  important  sign 
the  strong  desire  of  the  patient  to  sit  up,  and  "  the  judicious  Denman  " 
advised,  if  labor  was  delayed  from  this  cause,  that  the  patient  should 
stand  or  kneel  by  the  side  of  the  bed,  or  sit  upon  the  lap  of  one  of  her 
assistants. 

The  dangers  from  shortness  of  the  cord  are,  delayed  labor,  rupture  of 
the  cord,  premature  detachment  of  the  placenta,  and  inversion  of  the 
uterus.  , 

Delivery  by  expression  is  regarded  as  preferable  to  extraction  with 
the  forceps,  and,  after  the  child  is  partially  born,  should  delay  result 
from  a  tense  cord — then  only  can  a  certain  diagnosis  be  made — this  is 
to  be  cut. 

ABNORMAL,  RESISTANCE  OF  THE  BAG  OF  WATERS.  As  very  thin 
membranes  have  as  their  consequence  premature  rupture  of  the  bag  of 
waters,  so  if  these  membranes  are  very  thick  and  resisting  rupture  may 
be  delayed,  and  partial  placental  detachment  occur,  especially  if  the 
quantity  of  amnial  liquor  is  small.  The  remedy  for  this  condition,  of 
course,  is  artificial  rupture. 


CHAPTER   IX. 


INJURIES   OF   THE   MATERNAL   SOFT   PARTS. 

INJURIES  OF  THE  VULVA.  Tears  involving  the  nyrnphse  some- 
times occur  in  natural  as  well  as  in  instrumental  labor ;  one  of  these 
organs  may  be  divided  longitudinally,  or  partially  detached  from  its 
base.  There  may  be  a  tear  involving  the  inferior  margin  of  the  vesti- 
bule, and  it  may  extend  upward  to  the  side  of  the  clitoris,  possibly 
involving  the  corpus  cavernosum,  or  it  may  be  prolonged  inward  by 
the  side  of  the  urethra.  In  some  instances,  especially  if  the  corpus 
cavernosum  be  injured,  the  bleeding  is  great;  indeed,  cases  of  fatal 
hemorrhage  from  such  injuries  of  the  vestibule  have  been  reported.1 
If  hemorrhage  is  observed  following  the  birth  of  the  child's  head,  the 
body  being  undelivered,  it  must  necessarily  come  from  an  injury  of  the 
vulva. 

Arrest  of  hemorrhage  can  generally  be  accomplished  by  compression, 
but  it  would  be  better,  should  a  serious  tear  be  found,  to  use  catgut 
stitches ;  so,  too,  such  stitches  may  be  used  in  tears  of  the  nymphse  for 
the  purpose  of  preventing  deformity  of  the  part ;  moreover,  the  more 
completely  closed  these  wounds  are  the  greater  the  protection  of  the 
patient  from  infection,  for  if  an  injury  be  external  or  near  the  exterior, 
there  is  more  danger  of  the  absorption  of  poison  than  if  it  be  high  up 
in  the  vagina  or  of  the  uterus. 

In  addition  to  the  stitching,  the  injured  parts  may  be  freely  dusted 
with  iodoform  ;  so,  too,  in  cases  in  which  sutures  are  not  used,  a  similar 
application  should  be  made. 

TEARS  OF  THE  PERINEUM.  According  to  Olshausen,  unavoidable 
tears  of  the  perineum  occur  in  at  least  15  per  cent,  of  primiparse. 
Wiuckel  confirms  this  statement.  The  former  regards  tears  ot  the 
perineum  in  multipart  as  generally  preventable. 

Rents  of  the  perineum  usually  begin  at  its  anterior  margin  in  the 
median  line,  and  are  divided  into  partial  and  complete ;  by  the  latter  is 
meant  a  tear  which  extends  through  the  anal  sphincter.  In  some  cases, 
however,  the  tear  begins  in  the1  vagina  on  one  side  of  the  posterior 
column,  and  thence  passes  obliquely  to  the  median  line  and  ends  in  a 
tear  of  the  perineum.  A  superficial  rent  involves  only  the  skin  and 
subcutaneous  fascia.  A  rent  beginning  with  the  expulsion  of  the  head 
may  be  increased  by  the  shoulders. 

The  accident  is  more  liable  to  occur  in  old  primipane.  The  perineum 
has  sometimes  been  torn  by  the  introduction  of  the  hand  to  perform 
podalic  version.  To  the  forceps  must  be  attributed  a  large  number  of 

1  Young  :  Transactions  of  the  Edinburgh  Obstetrical  Society,  vol.  viii. ,  gives  two  cases  of  tears 
of  the  vestibule  followed  by  serious  hemorrhage  seen  by  him ;  one  of  the  patients  died  from  the 
bleeding. 


544  THE  PATHOLOGY  OF  LABOR. 

complete  ruptures  of  the  perineum.     Thus  Leopold  and  Wehle1  state 
that  in  105  cases  of  this  injury  the  forceps  had  been  used  in  70. 

The  majority  of  obstetric  authorities  hold  that,  as  a  rule,  a  torn  peri- 
neum should  be  stitched  as  soon  as  practicable  after  the  injury,  or,  at 
least,  that  the  operation  be  not  delayed  longer  than  sixteen  hours. 
When  performed  immediately  it  arrests  hemorrhage,  which,  in  some 
cases,  is  considerable;  in  all  cases  an  early  operation  lessens  the  danger 
of  septic  infection  taking  place  through  the  raw  surfaces ;  and  though 
an  incomplete  rent  that  seems  great  at  first  become  comparatively  small 
in  the  course  of  three  days,  yet  spontaneous  restoration  is  not  the  rule, 
while  restoration  is,  after  perineorrhaphy,  and,  therefore,  this  ought  to 
be  done  unless  there  are  some  strong  contra-iudications. 

The  stitches  can  be  introduced  most  conveniently  with  the  patient  lying 
upon  her  back,  and  her  hips  near  the  edge  of  the  bed.  A  hot  antiseptic 
vaginal  injection  is  first  used,  the  parts  being  thus  thoroughly  cleansed 
and  oozing  of  blood  lessened  ;  an  antiseptic  tampon  of  gauze  or  of  cotton 
is  placed  in  the  vagina  to  prevent  uterine  discharge  from  obscuring  the 
field  of  operation.  Supposing  the  rent  to  be  incomplete,  the  obstetrician, 
after  threading  his  needle,  which  may  be  curved  or  straight  according 
to  his  preference,  with  silkworm-gut — other  material  may  be  used,  silk, 
wire,  horsehair,  if  the  first-mentioned  be  not  at  hand — introduces  one 
or  two  fingers  of  the  left  hand  into  the  rectum  ;  then  with  the  right 
hand  enters  the  point  of  the  needle  half  an  inch  from  the  margin  of  the 
tear  at  the  lowest  part  of  the  latter,  on  the  one  side,  and  carries  it  across, 
buried  beneath  the  tissues,  unless  the  tear  be  complete,  in  all  its  course, 
until  it  emerges  at  a  corresponding  point  upon  the  opposite  side ;  in 
case  the  tear  be  complete,  the  needle  will  be  entered  into  the  tissues  a 
little  below  the  anal  rent — so  as  to  secure  the  torn  fibers  of  the  sphincter 
— and,  carried  across,  appears  in  the  median  line,  as  does  the  following 
suture,  and  then  passes  out  on  the  opposite  side  at  a  similar  point  to 
that  in  which  it  was  introduced.  After  placing  the  first  suture,  the 
second  and  then  the  third  are  introduced — rarely  will  a  larger  number 
be  necessary  ;  in  some  cases  only  one  is  required.  The  sutures  are  then 
tied,  or,  if  of  wire,  twisted.  Of  course,  instruments,  sutures,  and  the 
hands  of  the  operator  are  properly  antisepticized  ;  the  silkworm-gut  is 
rendered  more  pliable  by  being  first  soaked  for  a  few  minutes  in  very 
hot  water.  In  some  cases  it  is  necessary  before  stitching  to  cut  away 
loose  shreds  of  tissue.  If  the  tear  extends  up  the  recto- vaginal  wall, 
internal  stitching  will  be  required  before  employing  the  external  sutures, 
the  material  for  the  former  being  catgut,  and  a  curved  needle  being  used 
for  the  suture,  which,  as  a  rule,  should  be  continuous  ;  so,  too,  let  similar 
suturing  of  the  vaginal  surface  be  made.  Finally,  the  perineal  stitches 
are  placed. 

AFTER-TREATMENT.  By  some  it  is  hel$  important  to  tie  the  knees 
together,  to  use  the  catheter  at  regular  intervals,  and  to  keep  the  bowels 
confined  for  a  week  or  more.  By  no  probable  movement  of  the  limbs 
can  there  be  any  strain  upon  the  perineal  tissues  now  sewed  together — 
tissues  that  have  undergone  the  very  great  stretching  in  labor — and, 
therefore,  the  bandaging  of  the  knees  is  unnecessary ;  moreover,  the 

1  GeburtsMlfe  und  Gynakologie,  Band  ii. ,  1895. 


INJURIES  OF  THE  MATERNAL  SOFT  PARTS.  545 

bandage  increases  the  discomfort  of  the  patient  and  helps  to  imprison  the 
lochial  discharge  in  the  vagina,  and  is  thus  an  injury.  Hildebrandt 
objects  to  the  use  of  the  catheter  because  vesical  catarrh  is  very  liable  to 
result,  and  thinks  it  better  for  the  urine  to  be  discharged  spontaneously, 
if  possible.  Once  in  twenty-four  hours  the  vagina  should  be  carefully 
washed  out  with  a  warm  antiseptic  injection.  On  the  third  or  fourth 
day  the  bowels  may  be  moved  by  castor  oil  or  by  compound  licorice 
powder,  assisted  by  an  enema  of  warm  water  or  an  infusion  of  flax- 
seed  ;  subsequently  evacuation  should  be  had  at  least  once  in  forty-eight 
hours.  The  diet  need  not  vary  from  that  usually  given  after  labor. 
The  common  practice  is  to  remove  the  sutures  in  from  eight  to  ten 
days. 

CENTRAL  RUPTURE  OF  PERINEUM/  Central  rupture  of  the  peri- 
neum has  occasionally  occurred,  and  the  head  and  then  the  body  of  the 
child  have  passed  through  this  opening,  the  anterior  and  posterior  portion 
of  the  perineum  being  uninjured;  in  other  instances  the  rent  has  been 
caused  by  the  foot  or  elbow  of  the  child. 

Duncan2  asserts  that  the  passage  of  the  child  through  such  a  rent  rarely  hap- 
pens that  this  is  probably  sometimes  believed  in  after  the  event,  but  is  not  care- 
fully observed  during  the  process.  Reeve3  has  reported  a  case  of  central  rupture 
of  the  perineum,  without  implication  of  the  vulva,  occurring  in  a  multipara. 
"  The  rent  began  on  the  right  side,  near  the  junction  of  the  upper  fourth  with 
the  lower  three-fourths  of  the  labiuin,  followed  the  outer  boundary  of  the  labium 
downward,  and  crossed  the  perineum  to  the  rectum ;  both  the  anal  sphincters 
were  divided,  the  laceration  extending  upward  quite  an  inch  and  a  half.  The 
part  of  the  perineum  remaining  intact  at  the  posterior  commissure  and  along  the 
lower  part  of  the  right  labium  was  about -the  thickness  of  a  man's  thumb." 
Duncan4  has  called  attention  to  the  fact  that  central  perineal  rupture  may  in- 
volve only  the  skin,  or  the  mucous  membrane  of  the  vagina,  or  both  of  these 
with  their  subjacent  tissues,  while  there  remains  entire  some  tissue  intervening 
between  the  skin  and  the  vagina. 

Obstetricians  agree  that  if  the  beginning  of  a  central  rupture  is 
observed,  the  tissues  between  the  tear  and  the  vulvar  orifice  should  be 
at  once  divided,  thus  preventing  the  extension  of  the  rent  into  the  rec- 
tum ;  but  if  the  injury  is  not  discovered  until  after  delivery,  then 
division  of  the  anterior  bridge  is  not  advisable ;  the  tear  is  to  be  stitched 
by  interrupted  sutures,  preferably  of  silkworm-gut. 

INJURIES  OF  THE  VAGINA.  It  is  proposed  under  this  head  to  con- 
sider not  only  lacerations,  but  also  contused  and  perforating  wounds  of 
the  vagina  received  in  labor. 

It  is  convenient  to  divide  these  jnjuries  into  those  of  the  upper,  of  the 
middle,  and  of  the  lower  part  of  the  vagina.  Vaginal  tears  are  fre- 
quently associated  with  corresponding  injuries  of  the  uterus.  Never- 
theless, McClintock,5  from  the  statistics  of  the  Rotunda  Lying-in 
Hospital,  found  35  of  108  which  involved  the  vagina  only,  or  merely 

1  In  the  following  passage,  narrating  the  labor  of  Tamar  giving  birth  to  twins,  we  have, 
according  to  Luther  and  some  other  commentators,  medical  as  well  as  theological,  an  instance  or 
central  rupture  of  the  perineum  :  "  And  it  came  to  pass,  when  she  travailed,  that  the  one  put  out 
his  hand ;  and  the  midwife  took  and  bound  upon  his  hand  a  scarlet  thread,  saying,  this  came  out 
first.  And  it  came  to  pass,  as  he  drew  back  his  hand,  that,  behold,  his  brother  came  out ;  and  she 
said,  How  hast  thou  broken  forth?  the  breech  be  upon  thee;  therefore,  his  name  was  called 
Pharez."  (Pharez,  it  may  be  added,  means  breech.)  Genesis  xxxix.  :  28-29. 

'-  Transactions  of  the  American  Gynecological  Association,  vol.  i.  3  Ibid,  vol.  lii. 

4  Op.  cit.  »  Dublin  Journal  of  Medical  Science,  May,  1866. 

35 


546  THE  PATHOLOGY  OF  LABOR. 

the  os  uteri  with  it ;  it  is  thus  seen  that  the  cases  of  vaginal  injury 
alone  are  nearly  one-third  of  the  entire  number. 

Spontaneous  tears  of  the  vaginal  vault  are  more  frequently  transverse  than  longi- 
tudinal, while  those  in  the  middle  portion  of  the  vagina  are  generally  longitudinal. 
In  some  instances  the  vagina  has  been,  by  a  circular  rent,  partially  or  even 
completely  separated  from  the  uterus.  Johnson  and  Sinclair1  give  the  case  of  a 
patient  in  whom  a  fatal  injury  of  this  kind  occurred  ;  the  woman  was  a  multipara, 
but  delivery  being  impossible  because  of  cicatrices  in  the  lower  part  of  the 
vagina,  even  after  division  of  the  cicatricial  tissue  was  made  with  a  bistoury, 
craniotomy  was  performed  ;  death  occurred  the  next  day.  An  instance  of  per- 
foration of  the  posterior  cul-de-sac  by  a  vaginal  douche,  used  to  induce  labor  at 
the  eighth  month  of  pregnancy  because  of  pelvic  deformity,  is  given  by  Budin.2 
So,  too,  the  vaginal  vault  has  been  torn  by  the  badly  directed  blade  of  forceps 
or  cephalotribe.  Both  spontaneous  and  artificial  rents  of  the  upper  posterior 
portion  of  the  vagina  are  especially  liable  to  occur  in  case  there  be  a  pendulous 
abdomen  permitting  anterior  displacement  of  the  uterus,  for  by  this  displacement 
the  tissues  are  stretched  and  thinned.  Hart3  has  shown  that  the  posterior 
vaginal  wall  is  structurally  weak  at  its  upper  half-inch,  while  it  is  more  elongated 
than  the  anterior  wall  in  labor.  Rupture  is  most  common  where  the  posterior 
vaginal  wall  is  covered  by  peritoneum,  and  when  it  occurs  is  a  tension  tear  like 
cervical  rupture.  Instances  of  injury  to  the  vagina  anteriorly  and  posteriorly 
have  occurred  from  the  use  of  the  perforator  ;  in  one  case4  the  practitioner, 
wishing  to  open  the  child's  head,  made  a  rent  in  the  bladder,  permitting  the 
introduction  of  three  fingers,  and  in  another  case5  the  obstetrician,  attempting 
the  same  operation,  thrust  his  instrument  through  the  tissues,  aud  applied  it  to 
the  sacral  promontory,  mistaking  it  for  the  foetal  head.  Kupture  of  the  vaginal 
vault  has  oeen  caused  by  forcible  introduction  of  the  hand  into  the  uterus  for 
the  purpose  of  performing  version.6 

Prolapse  of  the  intestine  through  the  rent  has  been  observed  in  several  cases. 
Danyau*  in  1850  collected  17  cases  of  rupture  of  the  vagina  in  which  the  fcetus 
passed  into  the  abdominal  cavity ;  4  of  these  patients  recovered.  Others,  too, 
nave  recovered,  though  the  injury  permitted  prolapse  of  the  intestine.  Moysant 
has  reported  a  case  in  which  a  woman  being  in  labor  the  forceps  was  vainly 
applied,  and  then  delivery  by  podalic  version  tried ;  the  trunk  was  extracted, 
but  the  head  left  behind ;  the  woman  died  in  a  few  hours,  and  at  the  post-mortem 
the  foetal  head  was  found  in  the  left  side  of  the  abdominal  cavity,  having  entered 
through  a  rent  which  extended  from  the  uterine  junction  to  the  vulva. 

Schroder  refers  to  a  peculiar  case  recently  reported  by  Battlehner,  of  rupture 
of  the  anterior  vaginal  vault  with  prolapse  of  the  bladder  into  the  vagina. 

McClintock8  gives  as  the  causes  of  spontaneous  rupture  of  the  vagina  in  the 
cases  which  he  collected — 1,  diseases  of  the  vagina ;  2,  disproportion  between 
the  size  of  the  foetal  head  and  the  maternal  pelvis ;  and  3,  osseous  irregularity 
upon  the  inner  surface  of  the  pelvis.  While,  according  to  the  same  authority, 
the  recoveries  after  uterine  rupture  are  only  4|  per  cent.;  they  are  after  similar 
injury  to  the  vagina  12  per  cent. 

The  symptoms  that  have  been  most  frequently  observed  in  ruptures 
of  the  vagina  are  cessation  of  labor-pains,  hemorrhage,  recession  of  the 
presenting  part,  which,  however,  is  slight  unless  the  ftetus  enters  the 
abdominal  cavity ;  prolapse  of  intestine  or  of  omentum  is  a  not  infre- 
quent complication.  Shock,  too,  has  been  observed  in  many  cases. 

TREATMENT.  The  treatment  is  essentially  that  required  in  a  similar 
injury  to  the  uterus.  Prompt  delivery  is  indicated,  and  usually  this 

i  Midwifery. 

3  Des  Lesions  traumatlques  chez  la  Femme  dans  les  Accouchements  artiflciels.  Par  Pierre 
Budin.  Paris,  1878. 

3  Edinburgh  Obstetrical  Society's  Transactions,  vol.  viii. 

*  Provincial  Medical  Journal,  1843.  .  5  Budin,  op.  cit. 

0  Spiegelberg,  op.  cit.  7  Bulletins  de  la  SocifitS  anatomique,  1857. 

s  Archiv.  Med. 


INJURIES  OF  THE  MATERNAL  SOFT  PARTS.  547 

will  be  made  through  the  vagina ;  arrest  of  bleeding  will  be  accom- 
plished by  hot- water  injections,  by  sutures,  and  in  only  exceptional  cases 
need  a  tampon,  of  iodoform  or  creolin  gauze  for  example,  be  em- 
ployed ;  a  lateral  rent  or  one  involving  the  peritoneum  usually  re- 
quires a  drainage-tube. 

RENTS  OF  THE  MIDDLE  PORTION  OF  THE  VAGINA.  These  are 
generally  superficial ;  they  may  be  caused  by  careless  use  of  the  perfo- 
rator or  of  the  crochet,  or  the  vagina  may  be  torn  by  sharp  fragments  of 
bones  of  the  foetal  head  in  extraction  after  craniotomy.  Injury  may  be 
done  in  the  introduction  of  the  blade  of  the  forceps,  this  being  forced 
instead  of  caused  gently  to  "  feel  "  its  way  to  the  desired  point ;  so,  too, 
a  tear  may  be  made  in  the  extraction,  especially  in  case  the  blades  are  not 
accurately  applied  to  the  side  of  the  child's  head  and  kept  in  such  close 
relation,  for  the  foetal  head  ought  to  be  a  protection  to  the  vagina  from 
injury  by  the  borders  or  by  the  ends  of  the  forceps  blades.  Deep  tears 
of  the  middle  portion  of  the  vagina  may  occur  if  there  be  structural 
change  in  its  tissue,  whether  from  malignant  disease  or  from  cicatricial 
contraction.  Contused  wounds  of  the  vagina  most  frequently  result 
from  prolonged  impaction  of  the  head  in  the  pelvic  cavity — and  as  a 
consequence  subsequent  sloughing  occurs — which,  if  involving  the  an- 
terior wall  of  the  vagina,  may  result  in  a  vesico-vaginal  fistula,  or  if 
the  posterior,  a  recto- vaginal  fistula. 

TREATMENT.  It  rarely  happens  that  bleeding  from  wounds  of  the 
middle  portion  of  the  vagina  is  considerable,  and  its  treatment  does  not 
differ  from  that  required  in  similar  injury  of  the  upper  portion.  The 
most  important  part  of  the  treatment  of  the  colpitis  resulting  from  the 
injury  will  be  the  use  of  warm  antiseptic  injections — 1  part  of  corrosive 
sublimate  to  5000  of  water,  for  example,  or  a  2  per  cent,  creolin  mix- 
ture— and  following  the  injection  by  introducing  an  iodoform  supposi- 
tory ;  if  a  contused  wound  involving  the  anterior  wall  be  present,  great 
care  must  be  taken  to  prevent  distention  of  the  bladder ;  after  slough- 
ing of  any  part  of  the  vaginal  walls,  means  must  be  used  during  the 
healing  to  prevent  contractions,  metal,  glass,  or  hard-rubber  dilators 
being  introduced  from  time  to  time. 

As  showing  the  greater  liability  to  injuries  of  the  vagina  in  birth  in 
case  the  child  be  male,  the  fact  stated  by  Spiegelberg  is  significant :  that 
in  12  cases  of  vesico-vaginal  fistula  at  his  clinic  and  polyclinic,  in  the 
labors  from  which  they  resulted  all  the  children  were  boys. 

TEARS  OF  THE  LOWER  PORTION  OF  THE  VAGINA.  Though  these 
are  in  most  cases  associated  with  corresponding  injuries  to  the  perineum 
or  vulva,  yet  some  are  not,  and  therefore  should  be  considered  sepa- 
rately. So  far  as  spontaneous  injuries  of  this  class  are  concerned,  their 
most  frequent  cause  is  excessive  stretching  of  the  vagina;  they  are 
usually  superficial  and  situated  at  or  near  the  median  line ;  in  some 
cases,  however,  they  may  have  a  diagonal  course,  or  two  diagonal  tears 
may  be  united  with  a  median  tear,  having  approximately  the  form 
of  a  Y. 

Contused  wounds  resulting  from  prolonged  pressure  by  the  presenting  part 
are  also  found  here,  and  they  may  be  followed  by  sloughing,  which  may  end  in 
rectal  or  in  perineal  perforation.  Improper  use  of  the  forceps  is  to  be  credited 


548  THE  PATHOLOGY  OF  LABOR. 

with  many  injuries  to  the  lower  part  of  the  vagina ;  these  injuries  may  result 
from  too  rapid  extraction,  but  probably  their  most  frequent  cause  is  turning  the 
handles  of  the  forceps  too  soon  toward  the  abdomen  of  the  mother,  and  thus  the 
points  of  the  blades  are  withdrawn  from  the  child's  head  and  brought  directly 
against  the  posterior  wall  of  the  vagina,  making  more  or  less  deep  furrows  in  its 
tissues ;  a  similar  accident  has  occurred  from  the  attempt  to  withdraw  the  blades 
just  before  the  expulsion  of  the  head,  a  violent  pain  suddenly  expelling  the 
head,  while  the  obstetrician,  busy  with  the  manoauvre  mentioned,  was  powerless 
to  prevent  the  rapid  delivery.  Dupuy1  mentions  a  case  in  which,  the  feet  pre- 
senting, one  of  these  escaped  by  the  vulval  opening,  while  the  other,  pressing 
strongly  upon  the  vagina  posteriorly,  was  forced  through  the  perineum.  I  have 
seen  a  somewhat  similar  case,  only  the  foot  inflicting  the  injury  made  a  rent  at 
the  lower  portion  of  the  recto-vaginal  wall  and  protruded  through  the  anus, 
there  being  also  a  slight  tear  in  the  posterior  perineum.  Dr.  Barker2  has  pub- 
lished a  case  he  was  called  to  in  which  he  found  the  perineum  "  enormously  dis- 
tended by  the  pressure  of  the  head,  and  the  left  hand  and  forearm  projecting 
through  the  anus."  He  did  not  attempt  to  restore  the  member,  but  delivered 
with  the  forceps.  The  patient's  bowels  were  kept  confined  by  opium  for  ten 
days,  and  complete  cicatrization  followed. 

TREATMENT.  Bleeding  from  uncomplicated  lacerations  of  the  lower 
part  of  the  vagina  is  usually  only  slight,  and  therefore  can  only  excep- 
tionally require  means  for  its  arrest.  While,  too,  in  most  cases  these 
tears  are  only  superficial,  and  therefore  require  no  treatment  other  than 
cleanliness  and  the  use  of  antiseptics,  in  others  their  extent  is  such  that 
not  only  to  protect  from  septic  infection  and  to  secure  their  rapid  heal- 
ing, but  also  to  guard  against  possibly  permanent  injury  to  the  pelvic 
floor,  sutures  are  plainly  indicated.  Properly  prepared  catgut  is  the 
best  material  for  stitching  the  surfaces  together,  and  the  continuous 
suture  is  employed. 

THROMBUS  OR  H^EMATOMA  OF  THE  VULVA  OR  OF  THE  VAGINA. 
In  addition  to  the  injuries  that  have  been  mentioned,  there  may  be  tear- 
ing of  the  vessels  of  the  connective  tissue  of  the  vulva  or  of  the  vagina 
without  external  opening,  and  the  effused  blood  forms  a  mass  known 
as  labial,  or  vulval,  or  vaginal  thrombus  or  haematoma.  This  is  not  a 
frequent  accident.  Deneux,3  in  a  practice  of  more  than  forty  years, 
saw  but  three  cases,  and  Dnbois  a  like  number  in  14,000  deliveries. 
Winckel  gives  the  proportion  as  1  in  1600.  It  is  at  least  relatively 
more  frequent  in  primiparse  than  in  multipart.  Varicose  veins  are  not 
a  predisposing  cause;  Perrot's  statistics,  including  forty-three  cases, 
show  that  this  condition  was  present  in  only  two ;  Barker  states  that  in 
a  very  large  proportion  no  such  condition  preceded  the  thrombus. 

Among  the  causes  of  haBmatoma  mental  emotion,  violent  vomiting,  and  cough- 
ing have  been  given.  But  laying  aside  this  doubtful  etiology,  we  may  say  with 
Hervieux  that  the  determining  cause  of  this  affection  in  labor  is  the  prolonged 
stay  of  the  head  in  the  pelvic  cavity,  the  delay  arising  from  narrow  pelvis,  from 
resistance  of  the  perineum,  from  size  of  the  foetus,  etc.,  and  hence  excessive 
efforts  on  the  part  of  the  patient  to  overcome  the  obstacle  to  delivery.  Perrot 
has  shown  that  there  may  be  a  gliding  of  the  vaginal  walls  upon  the  peripheral 
tissues,  so  that  a  partial  detachment  occurs  from  tearing  of  portions  of  the  con- 
nective tissue,  and  thus  spaces  are  formed  in  which  blood  poured  out  by  the 
ruptured  vessels  collects.  Or  it  may  be  that  the  walls  of  vessels  are  thinned  by 
the  great  pressure  from  the  foetus,  and  when  that  pressure  ceases,  a  new  wave  of 

1  Considerations  relatives  aux  DSchirures  du  Vagin  a,  la  Suite  de  1' Accouchement.    Paris,  1822. 
*  The  Puerperal  Diseases,  p.  42.  8  Maladies  Puerp6rales,  Hervieux. 


INJURIES  OF  THE  MATERNAL  SOFT  PARTS.  549 

blood  distending  them,  they  give  way.  According  to  some  authorities,  the  vessels 
that  rupture  are  venous,  but  Winckel  says  there  is  no  question  that  the  wound 
of  an  artery,  as  well  as  of  a  vein,  may  give  rise  to  a  hsenmtoma,  even  though  the 
effusion  is  most  commonly  of  venous  origin.  In  35  out  of  43  cases  collected  by 
Perrot  the  hemorrhage  did  not  occur  until  after  labor.  Dewees1  has  given  an 
instance  in  which  the  tumor  formed  ten  minutes  after  the  birth  of  the  first  of 
twins,  and  was  ruptured  by  the  descent  of  the  second  child,  the  patient  recover- 
ing. Madame  Sasanoff,  in  connection  with  a  case  under  her  care  in  the  Mater- 
nity of  Kolonna,  St.  Petersburg,  has  reported  five  others2 — that  of  Dr.  Dewees 
not  being  included — as  the  only  ones  she  could  find  published  in  which  the 
hsematoma  formed  in  the  interval  between  the  birth  of  twins.  Of  these  five, 
four  were  fatal.  She  believes  the  rule  of  practice  ought  to  be  that,  when  there 
exists  the  least  appearance  of  the  formation  of  a  thrombus,  the  delivery  should 
be  hastened,  and  that  to  this  end  version  and  extraction  of  the  second  child 
should  receive  a  large  application,  so  much  the  more  as  the  escape  of  the  first 
child  favorably  affects  the  dilatation  of  the  orifice,  and  facilitates  the  intro- 
duction of  the  forceps  or  the  hand  into  the  genital  canal.  If  the  delivery  be 
delayed, the  haematoma  rapidly  increases  in  size,  and  rupture  or  incision  maybe 
necessary  for  the  passage  of  the  child,  and  such  early  rupture  or  incision  makes 
the  prognosis  quite  unfavorable. 

The  tumor  varying  in  size  from  a  hen's  egg  to  a  child's  head3  usually 
appears  a  short  time  after  labor,  but  exceptionally  several  days  may 
intervene.  Schroder  refers  to  a  case  reported  by  Heifer  in  which  it  was 
first  seen  on  the  twenty-first  day  ;  in  such  instances  the  exciting  cause 
was  violent  bodily  exertion. 

Hsematoma  of  the  vulva  is  more  frequent  than  of  the  vagina.  The  labia 
majora  are  oftener  affected  than  the  labia  minora.  The  effusion  may  extend  to 
the  connective  tissue,  making  a  vulvo-perineal  thrombus  :  "The  blood  is  gener- 
ally extravasated  into  the  subcutaneous  cellular  tissue  in  the  perineum  between 
the  superficial  and  median  fascia,  in  the  vagina  into  the  submucous  tissue,  or 
into  the  cellular  tissue  encompassing  the  vagina;  yet  there  are  cases  (Cazeaux 
and  Hugenberger)  in  which  it  has  extended  along  the  vagina  up  to  the  perito- 
neal cellular  tissue,  and  posterior  to  the  peritoneum  up  to  the  kidneys,  anteriorly 
in  front  of  the  peritoneum  up  to  the  navel,  and  on  the  sides  as  far  as  the  sacrum."4 

The  tumor  is  in  the  majority  of  cases  unilateral ;  and  its  formation 
is  usually  preceded  by  severe  pain  ;  the  surface  is  smooth,  discolored, 
livid  or  violet,  and  it  presents  to  the  touch  more  or  less  elasticity  with 
or  without  fluctuation.  If  the  hemorrhage  be  great,  the  symptoms  of 
acute  anaemia  are  present ;  but  death  does  not  follow  unless  the  hasma- 
toma  ruptures,  and  then  it  may  be  very  rapid.  Recovery  generally 
takes  place.  Thus  Winckel  found  only  six  that  were  fatal  in  fifty; 
Barker  met  with  two  deaths,  both  from  puerperal  fever,  in  thirteen  hos- 
pital cases,  while  of  nine  in  consultation  and  in  private  practice  all 
recovered.  The  prognosis  will  be*  governed  by  the  size  of  the  thrombus, 
and  by  whether  it  occurs  before  or  after  delivery  :  the  larger  the  tumor, 
of  course  the  greater  the  danger;  and,  on  the  other  hand,  the  case  is 
more  favorable  if  the  formation  occurs  after  the  labor  than  during  it. 
The  termination  may  be  by  resolution,  and  this  may  happen  even  if 
the  tumor  be  as  large  as  the  fist,  by  suppuration,  by  rupture,  or  by 
gangrene. 

1  Diseases  of  Females:  Of  Bloody  Infiltration  in  the  Labia  Pudendi 

2  Annales  de  Gynecologic  December,  1884. 

3  An  instance  in  which  the  tumor  was  the  size  of  a,child's  head,  and  interfered  with  the  delivery 
of  the  placenta,  is  given  in  the  Centralblatt  f.  Gynakol.,  1889,  p.  526. 

4  Winckel,  op.  cit. 


550  THE  PA THOL OG  Y  OF  LABOR. 

TREATMENT.  During  the  formation  of  a  hsematorua  we  endeavor  to 
lessen  the  effusion  of  blood  by  the  application  of  an  ice-bag  and  by  com- 
pression. If  rupture  occurs,  an  astringent  tampon  must  be  applied  and 
pressure  also  used.  If  a  hsematoma  appears  during  labor,  and  presents 
an  obstacle  to  the  deli  very  of  the  child,  even  by  forceps,  though  such  con- 
dition is  quite  exceptional,  "  incise  at  once,  remove  all  the  clots  that  have 
formed,  and  then  deliver  by  the  forceps,"  and  afterward  compresses  of 
cotton  batting  saturated  with  the  solution  of  persulphate  of  iron  are  to  be 
used  and  pressure  made,  constitute  the  directions  of  Barker.  After  labor, 
incision  may  be  rendered  necessary  by  threatened  gangrene ;  but  it  is 
always  better  if  this  can  be  delayed  for  three  or  four  days  after  the 
development  of  the  hsematoma,  for,  as  observed  by  Schroder,  the  longer 
we  can  wait  the  less  danger  from  consecutive  hemorrhage ;  nevertheless, 
Chaussier  mentions  a  case  in  which  the  incision  was  not  made  for  a 
week,  yet  hemorrhage  occurred,  and  Baudelocque  one  in  which  the  open- 
ing was  not  made  until  three  weeks  after  the  tumor  was  formed,  and  the 
following  hemorrhage  was  so  great  as  to  require  the  tampon. 

TEARS  OF  THE  CERVIX.  Lateral  tears  of  the  cervix  almost  inva- 
riably occur  in  a  first  labor,  that  upon  the  left  side  being  usually  deeper 
than  the  corresponding  one  upon  the  right.  In  some  cases  the  tear 
extends  to  the  vaginal  vault,  more  rarely  above  it  so  that  the  connective 
tissue  is  involved,  and  still  more  rarely  the  injury  may  reach  to  the 
peritoneum.  In  the  multipara  some  tearing  also  may  occur,  but  usually 
the  rents  are  not  so  deep,  and  less  frequently  lateral.  The  injuries 
referred  to  occur  not  only  in  spontaneous,  but  also  in  artificial  delivery, 
both  manual  and  instrumental ;  the  application  of  the  forceps  and  ex- 
traction of  the  foetus  before  complete  dilatation  of  the  os  has  occurred, 
as  well  as  rude  and  hurried  dilatation  of  the  os  by  the  hand  or  rapidly 
drawing  out  the  child  after  podalic  version,  is  very  liable  to  cause  this 
accident ;  when  the  placenta  is  prsevia,  severe  and  even  fatal  laceration 
of  the  cervix,  the  tear  extending  upward  to  the  body  of  the  uterus  and 
downward  into  the  vagina,  has  been  known  to  result  from  too  rapid 
dilatation  of  the  os  and  too  hasty  extraction  of  the  child. 

Lacerations  of  the  vaginal  cervix  are  physiological  in  the  great  majority  of 
cases,  neither  immediately  nor  remotely  demanding  professional  interference ; 
so  far  as  ulterior  consequences  are  concerned,  probably  an  exaggerated1  impor- 
tance has  been  attached  to  these  injuries  of  the  cervix,  more  especially  in  this 
country,  since  Emmet  has  devised  the  operation  known  by  his  name,  an  opera- 
tion very  beneficial  in  suitable  cases,  but  often  done,  as  Emmet  himself  has 
pointed  out,  unnecessarily. 

In  exceptional  cases  serious  hemorrhage  comes  from  the  rent  in  the 
cervix,  and  immediate  arrest  of  the  bleeding  is  demanded.  This  may 
lie  accomplished  by  copious  injections  of  hot  water,  by  the  pressure  of 
properly  applied  iodoform  gauze,  but  the  surest  means  is  the  suture ; 
for  its  application  the  cervix  must  be  seized  with  suitable  forceps,  and 

1  Some  years  ago  the  late  Dr.  Holmes  pleasantly  remarked  that  Mr.  Huxley  had  given  bioplasm 
about  all  it  could  bear.  I  am  quite  sare  that  some  practitioners  have  given  a  lacerated  cervix  a 
good  deal  more  than  it  can  bear.  The  assumption  that  healed  and  innocent  physiological  tears  of 
the  cervix  require  a  plastic  operation  by  which  the  os  and  cervix  of  the  woman  who  has  borne  a 
child  shaJ  be  restored  to  their  condition  prior  to  childbirth,  Is  an  error  from  which  originates  a 
great  deal  of  mere  carpenter  work  of  no  profit  whatever  except  to  the  operator. 


INJURIES  OF  THE  .MATERNAL  SOFT  PARTS. 


drawn  down  to  the  vulva,  when  the  stitches  can  be  readily  introduced 
with  the  injured  part  thus  exposed ;  silkworm-gut  is  the  best  material 
for  stitches. 

Transverse  tears  of  the  cervix  are  comparatively  rare.  They  usually  involve 
only  the  anterior  lip,  and  then  result  from  its  being  forcibly  held  by  the  descend- 
ing head  against  the  anterior  wall  of  the  pelvis.  Schroder  refers  to  the  accident 
as  more  frequent  if  there  is  induration  of  the  cervical  tissue;  he  also  mentions  a 
case  of  Martin's  in  which  there  was  found  a  polypoid  body  formed  by  the  par- 
tially detached  lip  of  the  uterus. 


ANNULAR  LACERATION  OF  THE  CERVIX. 

A  few  cases  of  what  has  been  termed  annular  separation  of  the  cervix  have 
been  recorded.  This  accident  results  from  an  unyielding  cervix  and  strong 
uterine  contractions  Barnes1  refers  to  a  case  reported  by  Gervis  in  which  ring- 
form  detachment  was  not  complete.  It  was  replaced  without  sutures,  as  the 
patient  was  very  prostrate.  She  recovered,  and  the  ring  reunited.  Duparcque2 
mentions  meeting  with  a  case  in  which  the  entire  anterior  lip  was  detached,  so 
that  at  first  it  seemed  as  if  there  were  a  double  os  uteri. 

RUPTURES  OF  THE  UTERUS.  Rupture  of  the  uterus  is  one  of  the 
gravest  accidents  that  can  occur  to  the  pregnant  or  parturient  woman, 
for  her  child  almost  without  exception  perishes,  and  her  own  life  is  lost 
in  the  great  majority  of  cases. 

FREQUENCY  OF  RUPTURE.  This  is  variously  stated  by  different 
authors : 


Collins  found 
McClintock  . 
Bandl    . 
Jolly       . 
Ramsbotham 
Von  Franque 


1  rupture  in   482  labors. 


737 
1183 
3403 
4429 
3225 


Winckel  saw  rupture  of  the  uterus  during  five  years  in  the  Munich 
clinic  in  6  cases  out  of  4000  labors. 

In  some  instances  the  rupture  is  what  has  been  termed  "silent,"  as  will  be 
explained  hereafter,  and  the  woman  perishes  of  hemorrhage,  or  of  septic  infec- 

1  Obstetric  Medicine  and  Surgery.    A  similar  case  will  be  found  in  the  Transactions  of  the 
Philadelphia  Pathological  Society,  vol.  i.,  reported  by  Dr.  Keller. 

2  Histoire  complete  des  Ruptures  et  des  Dechirures  de  FIT  terns,  etc. 


552 


THE  PATHOLOGY  OF  LABOR. 


tion,  and  only  by  accident,  if  an  autopsy  is  made,  is  the  injury  known ;  in  the 
absence  of  such  autopsy  death  is  attributed  to  one  or  the  other  cause  mentioned, 
the  true  condition  being  unknown.  Hence  it  is  probable  the  accident  occurs 
oftener  than  statistics  lead  us  to  believe. 

RUPTURE  IN  PREGNANCY.  This  may  be  spontaneous  or  result 
from  external  violence.  The  cicatrix  remaining  after  the  Csesareau 
operation  may  give  way,  or  the  thinned  wall  of  a  rudimentary  horn 
yield  to  the  pressure  of  the  growing  ovum,  or  a  blow  upon  the  abdo- 
men, or  a  fall,  causes  a  tear  in  the  normal  uterus. 

Spontaneous  rupture  in  pregnancy  has  followed  dancing,  vomiting, 
lifting  a  heavy  weight,  and  great  fatigue.  Barnes,  op.  cit.,  gives  illus- 


trative cases. 


FIG.  216. 


TRANSVERSE  OR  SEMI-CIRCULAR  GRINDING  THROUGH  OF  THE  UTERUS.    (From  BARNES.) 

RUPTURE  DURING  LABOR;  ITS  CAUSES.  In  considering  the  etiology 
of  this  accident,  it  is  convenient  to  refer  first  to  the  rarer  cases  of  this 
accident.  Rupture  may  be  consequent  upon  attrition,  the  uterine  tissue, 
usually  cervical,  being  forced  against  abnormal  bony  projections  from 
some  portion  of  the  pelvic  inlet,  exostoses  of  pelvic  bones ;  and  thus 
usur,  a  wearing  away  of  those  tissues,  results.  Naegele  states  that 
Kilian  has  drawn  especial  attention  to  a  deformity  of  the  ilio-pectineal 
eminence  in  which  this,  instead  of  presenting  its  normal  oval  shape,  has 
a  spine-like  process  ;  similar  sharp  projections  may  occupy  other  parts 
of  the  pelvis;  to  the  basin  thus  deformed  the  name  of  Slachelbecken, 
pelvis  spinosa,  was  given ;  and  Kilian  showed  the  injurious  effect  in 


INJURIES  OF  THE  MATERNAL  SOFT  PARTS.  553 

labor  resulting  from  this  cause.  Depaul  has  stated  that  four  out  of 
twenty-four  deformed  pelves  in  his  collection  have  exaggerated  develop- 
ments of  particular  parts,  forming  knife-like  projections ;  according  to 
his  observation,  this  deformity  was  most  frequent  at  the  pubic  crest. 
The  following  remarkable  case  is  quoted  by  Duparcque  :l  A  woman 
had  been  in  labor  twelve  hours,  the  presentation  being  pelvic.  The  os 
uteri  was  not  yet  completely  dilated  when  all  the  anterior  part  of  the 
neck,  from  one  side  to  the  other,  separated.  Immediately  the  foetus 
passed  into  the  abdominal  cavity,  and  it  was  extracted  with  great  diffi- 
culty in  less  than  two  hours;  it  was  dead.  The  mother  died  five  hours 
after  being  delivered.  The  basin  was  found  a  little  narrow  ;  the  point 
of  the  sacrum  had  passed  through  the  posterior  part  of  the  uterus  (was 
this  the  sacro-vertebral  angle?);  the  internal  and  salient  border  of  the 
pubis  and  of  the  iliac  bones  resembled  somewhat  the  edge  of  a  paper- 
cutter,  and  had  cut  all  the  thickness  of  the  uterus  as  if  it  had  been 
divided  by  a  ligature.  Breus2  has  published  a  case  of  injury  done  to 
the  uterus  by  its  tissues  being  worn  through  in  consequence  of  the  pres- 
sure of  the  head  of  the  child  forcing  these  tissues  against  the  sharp  pro- 
montory of  a  rhachitic  pelvis. 

Not  only  may  pelvic  deformity  cause  such  attrition,  but  I  believe  that  it  may 
also  result  from  an  irregular  bony  surface  of  the  foetal  body  being  forced  against 
the  uterine  walls,  hour  after  hour,  by  uterine  contractions  ;  such  a  surface  is 
presented  by  the  jagged  margin  of  the  imperfect  arches  of  a  spina  bifida  after 
rupture  of  the  sac  has  occurred.  This  belief  depends  upon  my  having  several 
years  ago,  in  a  judicial  investigation,  a  midwife  having  been  arrested  for  mal- 
practice, examined  the  foetus  and  the  ruptured  uterus  of  the  dead  mother.  The 
rupture  involved  the  cervix  and  the  lower  third  of  the  body  of  the  womb  upon 
the  right  side ;  in  the  labor  the  pelvis  presented  with  the  sacrum  to  the  right, 
and  the  most  rational  explanation  of  the  accident  was,  to  my  mind,  that  which 
has  been  stated. 

In  rare  cases  no  cause  can  be  assigned  for  the  accident.  Thus 
Winckel  remarks  that  the  cases  of  Alexander  Simpson  and  of  Hof- 
meier  are  very  remarkable  and  difficult  to  explain.  "In  Simpson's 
case  the  laceration  extended  from  the  fundus  uteri  to  the  os  on  the  left 
side ;  in  Hofmeier's  the  laceration  was  of  the  same  length,  but  on  the 
right  side ;  both  occurred  in  pluriparae  and  the  pains  were  not  very 
strong  ;  the  former  showed  an  abnormal  fatty  condition  of  the  uterine 
muscular  structure,  which  was  absent  in  the  latter.  The  most  remark- 
able case  of  spontaneous  rupture  of  an  otherwise  normal  uterus  is,  how- 
ever, the  one  which  Ingersley  observed  in  a  32-year-old  VH-para  in 
the  eighth  month  of  pregnancy,  in  whom  a  rupture  from  the  fundus  to 
within  one-half  inch  of  the  internal  os  occurred  without  any  external 
violence ;  the  child  escaped  into  the  peritoneal  cavity  and  the  woman 
died  in  two  hours." 

Passing  from  these  rare  and  exceptional  cases,  we  have  now  to  con- 
sider the  causes  of  the  accident  as  it  most  frequently  occurs.  So  far  as 
immediate  causation  is  concerned,  it  may  be  stated  that  rupture  of  the 
uterus  is  spontaneous  or  from  violence,  and  this  violence  may  be  done 
by  the  instrument  or  by  the  hand  of  the  obstretriciau.  Duparcque,  in 

1  Op.  cit.  2  Ueber  perforirende  Usur  des  Uterus,  Wien.  med.  Blatter. 


554  THE  PATHOLOGY  OF  LABOR. 

his  well-known  work,  gives  as  his  first  conclusion  that  ruptures  of  the 
uterus  in  labor  are  caused  by  the  contractions  of  the  organ.  Trask,  in 
his,  at  the  time  of  publication,  exhaustive  study1  of  the  accident,  said  : 
"Unless  caused  by  direct  violence,  rupture  must,  in  almost  every  case, 
be  the  result  of  the  contraction  of  the  uterine  fibres,  whether  the  uterus 
be  healthy  or  diseased."  Tyler  Smith  expressed  the  following  opinion  : 
"  Undoubtedly  cases  of  rupture  of  the  uterus  do  occur  which  are  de- 
pendent upon  inflammatory  action,  either  during  or  before  labor,  or 
upon  malignant  diseases  of  the  uterus ;  but  such  cases  are  rare  com- 
pared with  rupture  from  self-contraction  of  the  uterus."  Jolly  stated 
that  the  true  cause  is  more  or  less  violent  uterine  contraction.  But  con- 
tractions of  the  uterus,  though  violent,  could  not  rupture  the  uterus  if 
normal  conditions  are  present,  and  therefore  behind  this  cause  there 
must  be  others  that  predispose  or  otherwise  contribute  to  the  result,  and 
to  these  our  attention  will  now  be  directed. 

The  accident  occurs  more  frequently  in  multiparse2  than  in  primi- 
parse,  the  latter  furnishing  only  12  per  cent,  of  the  entire  number.  The 
influence  of  multiparity  is  explained  by  Charpentier  as  causing  thinness 
of  the  wall  of  the  uterus  and  changes  in  its  tissue,  with  enfeebling  of 
power.  Klein  wachter  and  others,  however,  believe  that  healthy  uteri 
rupture  more  frequently,  for  they  only  contract  powerfully.  Scanzoni 
suggests  the  greater  frequency  of  shoulder  presentations ;  to  this  may 
be  added  the  greater  size  of  the  children.  The  accident  is  more  fre- 
quent in  the  births  of  male  than  of  female  children — of  67  children, 
48  were  male,  only  19  female.  They  are  more  frequent,  according  to 
Baudl,  among  the  poor  than  among  the  rich. 

It  is  probable  that  the  untimely  administration  of  ergot,  or  using  it  in  too 
large  doses,  must  be  considered  the  chief  factor  in  causing  rupture  of  the  uterus 
in  some  cases.  The  late  Dr.  Hugh  L.  Hodge  stated  that  he  had  never  met  with 
this  or  seen  a  case  of  rupture,  with  perhaps  one  exception,  in  which  ergot  had 
not  been  given.  Dr.  Meigs  has  referred  to  three,  and  Dr.  Bedford  to  four  cases, 
in  which  it  was  believed  that  ergot  was  the  cause.  Similar  instances  are  given 
by  Marot,  and  it  would  be  easy  to  increase  the  list  to  large  proportions,  especi- 
ally if  cases  were  collected  from  the  practice  of  midwives  in  this  country,  who, 
usually  attending  cases  of  labor  for  low  fees,  too  often  endeavor  to  hurry  the 
labor  by  giving  ergot  in  the  first  stage. 

The  injurious  effect  of  ergot  given  with  a  free  hand  in  the  first  stage  of  labor 
can  be  readily  understood  when  we  remember  that  for  the  occurrence  of  spon- 
taneous rupture  of  the  uterus  the  chief  immediate  factors  are  active  contraction 
in  the  effort  to  overcome  great  or  insuperable  resistance.  The  undilated  or  par- 
tially dilated  os  is  a  barrier  to  the  passage  of  the  foetus ;  if  time  be  given,  the 
tissues  being  healthy,  gradually  yield  and  perfect  dilatation  results  ;  but  if  the 
uterus  is  stimulated  to  excessive  activity  the  resisting  os  prevents  escape  of  the 
presenting  part,  and  the  force  prematurely  or  unduly  evoked  is  expended  upon 
the  thinned  lower  segment  of  the  uterus,  and  rupture  follows. 

In  some  cases  of  pathological  change  in  the  cervix,  as  from  malig- 
nant disease,  rupture  follows  the  vain  effort  to  overcome  the  resistance. 

1  American  Journal  of  the  Medical  Sciences,  1848  and  1856. 

2  Playfair  states :  "  Tyler  Smith  contended  that  ruptures  are  relatively  as  common  in  first  as  In 
subsequent  pregnancies."    Charpentier  says  that  all  authors,  except  Tyler  Smith,  admit  the  influ- 
ence of  multiparity.    How  these  statements  can  be  reconciled  with  the  following  language,  let 
others  decide  :  "  It  is  an  interesting  and  remarkable  fact  that  ruptures  of  the  uterus  seldom  hap- 
pen to  primiparous  women."    (Lectures  on  Parturition  and  the  Principles  and  Practice  of  Obstet- 
rics.   By  W.  Tyler  Smith.    Lancet,  vol.  ii.  p.  495.) 


INJURIES  OF  THE  MATERNAL  SOFT  PARTS.  555 

It  must  be  remembered  that  in  labor  the  uterus  consists  of  two  portions, 
one  active,  the  other  passive  ;  an  upper  portion  which  seeks  to  expel 
the  child,  and  a  lower  portion  which  is  stretched  so  as  to  permit  that 
expulsion.  Now  if,  for  example,  there  be  a  shoulder  presentation,  ex- 
pulsion is  impossible.  So,  too,  if  there  be  excessive  size  of  the  child, 
as  from  hydrocephalus,  the  same  element  of  disproportion  between  the 
passenger  and  the  passage  is  present.  Schuchard1  in  73  cases  of  uterine 
rupture  found  hydrocephalus  in  18. 

Winckel  describes  the  occurrence  of  spontaneous  rupture  as  follows : 

"  Some  obstruction,  whether  it  be  hardness  or  rigidity  of  the  external  os,  or  an 
unusual  size  of  the  head  (by  hydrocephalus),  or  a  faulty  attitude  (face  presenta- 
tion, prolapse  of  an  arm),  prevents  dilatation  and  retraction  of  the  cervix  over 
the  presenting  part,  while  it  is  continually  forced  by  the  body  of  the  child  under 
the  contraction-ring;  hence  the  lower  uterine  segment  becomes  thinner  and 
thinner,  until,  finally,  its  fibres  separate,  by  reason  of  the  renewed  force  of  the 
pains,  at  the  points  which  have  been  most  tensely  stretched  and  attenuated,  the 
laceration  perforating  rapidly  from  within  outward." 

SYMPTOMS  OF  THREATENED  UTERINE  RUPTURE.  The  premoni- 
tory symptoms  are  the  tense  condition  of  the  round  ligaments,  the  great 
thinning  of  the  lower  uterine  segment,  the  ascension  of  Schroder's  con- 
traction-ring, so  that  from  its  normal  position  near  the  pelvic  inlet  it 
may  now  be  only  the  breadth  of  two  or  three  fingers  below  the  umbili- 
cus ;  this  ring  can  be  recognized  by  palpation,  and  during  a  uterine  con- 
traction can  in  some  cases  be  seen  making  a  somewhat  obliquely  lying 
furrow  across  the  abdomen,  while,  at  the  same  time,  that  portion  of  the 
uterus  below  this  furrow  "  is  prominent  as  if  it  were  a  distended  blad- 
der ; "  but  the  use  of  the  catheter  will  prevent,  in  a  case  of  doubt,  such 
mistake. 

The  finger  in  the  vagina  passes  readily  between  the  presenting  part 
and  the  cervical  wall,  which  is  everywhere  found  extremely  thin.  The 
general  condition  of  the  patient  also  foretells  the  accident.  She  is  rest- 
less and  suffers  not  only  during  uterine  contractions,  but  also  in  the 
intervals ;  the  abdomen  is  tender  f  the  suffering  and  the  anxiety  cause 
an  excited  and  frequent  pulse,  and  there  is  some  elevation  of  tempera- 
ture ;  her  countenance  expresses  anxiety.  Instances  of  this  variety 
of  rupture  that  do  not  present  premonitory  symptoms  are  quite  ex- 
ceptional. 

Tears  of  the  uterus  caused  by  the  application  of  the  forceps  when  the 
os  is  not  sufficiently  dilated,  or  by  the  rude  and  rapid  dilatation  with 
the  hand,  or  by  the  manual  extraction  of  the  child  in  a  case  of  partial 
expansion  of  the  os,  have  been  previously  mentioned.  It  only  remains 
to  refer  to  this  accident  in  case  of  threatened  rupture  in  consequence  of 
obstetric  manipulations.  The  shoulder,  for  example,  presents,  and  the 
vain  labor  has  continued  for  hours ;  the  obstetrician  performs  podalic 
version,  and  although  accomplished  with  ease,  it  may  be,  as  the  last 
straw  that  breaks  the  camel's  back,  so  the  introduction  of  fingers  or 
hand,  even  done  with  the  utmost  gentleness,  may  cause  tearing  of  the 
uterus. 

1  Ueber  die  Schweirigheit  der  Diagnose  und  die  Hauflgheit  der  Uterusruptur  bei  fotaler  Hydro- 
cephalie.    Berlin  thesis,  1884. 

2  Spiegelberg. 


556 


THE  PATHOLOGY  OF  LAEOR. 


Before  mentioning  the  symptoms  of  rupture  of  the  uterus,  a  word  may  be 
said  of  those  cases  in  which  there  are  no  indications  of  the  accident. 


FIG.  217. 


contraction-ring 


't round  ligament 


contraction-ring 

round  ligament 


internal  os  • 


external  os 


SHOULDER  PRESENTATION.   THREATENED  RUPTURE  OF  THE  STRETCHED  LOWER  SEGMENT 
OF  THE  UTERUS  AND  CERVIX.    (After  SCHRODER.) 

Hervieux1  narrates  a  case  from  the  practice  of  Dubois,  in  which  he  performed 
podalic  version  on  account  of  narrowed  inlet ;  the  woman  died  the  next  day,  no 
symptoms  of  uterine  rupture  having  been  manifested,  yet  there  was  found  at  the 
post-mortem  an  irregular  rent  involving  a  part  of  the  anterior  wall  of  the  vagina, 
the  entire  length  of  the  neck  in  front,  and  a  portion  of  the  left  side  of  the 
uterus.  He  also  refers  to  a  case  occurring  in  the  Maternite  in  his  service  in 
which  Tarnier  by  external  means  changed  a  pelvic  into  a  vertex  presentation  ; 
the  woman  was  delivered  on  the  9th  and  died  on  the  llth  of  November,  and 
at  the  autopsy  there  was  found  a  rent  in  the  side  of  the  neck  a  little  more 
than  two  inches  long,  extending  from  the  internal  os  to  the  union  between  the 
neck  and  the  vagina.  In  a  paper  presented  some  years  ago  to  the  Philadelphia 
County  Medical  Society,  I  narrated  a  case  of  uterine  tear  which  was  not  sus- 
pected during  life,  but,  the  woman  dying  of  septicaemia,  a  post-mortem  showed 
that  there  was  a  complete  rent  involving  the  left  side  of  the  cervix  and  the  lower 
third  of  the  body  of  the  uterus.  Since  that  time  a  medical  gentleman  of  this 
city  brought  me  the  uterus  of  a  woman  who  died  in  labor  from  hemorrhage,  so 
reported,  too,  in  the  certificate  to  the  Board  of  Health,  and  examination  showed 
that  the  cause  of  the  hemorrhage  was  a  tear  extending  from  the  external  os 
nearly  as  high  as  the  contraction-ring.  Hervieux  remarks  that  in  some  cases 
the  uterine  tear  is  made  silently — neither  pain  nor  complaint  nor  crisis,  and  if 
the  patient  dies,  as  is  usually  the  case,  one  is  astonished  to  find  at  the  autopsy  a 
rupture  which  had  not  been  even  suspected. 

Winckel,  after  referring  to  these  cases,  as  given  in  the  first  edition  of  this 
work,  adds  a  similar  one  occurring  under  his  observation. 


Traitfi  clinique  et  pratique  des  Maladies  puerp6  rales. 


INJURIES  OF  THE  MATERNAL  SOFT  PARTS. 


557 


If  we  add  to  these  silent  tears,  many  of  which  remain  unknown  because 
autopsies  in  private  practice  are  not  frequent,  and  a  few  in  which  death  does 
not  follow  the  accident — those  cases  which,  though  recognized  by  the  practi- 
tioner, are  not  made  known— it  is  probable,  as  has  been  previously  stated,  that 
the  accident,  though  by  no  means  frequent,  is  less  rare  than  published  statistics 
indicate. 

POSITION  AND  EXTENT  OF  TEARS.  Usually  the  rupture  involves 
the  lower  uterine  segment  and  the  cervix,  but  it  may  extend  upward 
into  the  contraction-ring  or  downward  into  the  vaginal  wall.  Usually, 
too,  the  peritoneum  is  torn,  so  that  there  is  a  direct  communication  be- 
tween the  uterine  and  abdominal  cavities  ;  exceptionally  the  peritoneum 
is  not  injured,  and  then  the  rupture  is  incomplete.  The  tears  are  rarely 
longitudinal,  but  they  may  be  transverse  or  oblique ;  they  may  be  lat- 
eral, anterior,  or  posterior.  A  part  of  the  foetus  usually  enters  the 
abdominal  cavity,  sometimes  almost  all  or  even  the  entire  body  ;  and, 
on  the  other  hand,  a  portion  of  intestine  may  prolapse  through  the  rent. 

SYMPTOMS  OF  RUPTURE.  It  may  be  that  during  a  pain  of  unusual 
severity,  or  an  obstetric  manipulation,  as  the  introduction  of  the  hand 
for  the  purpose  of  version,  the  patient  has  sudden  suffering  of  the 
greatest  intensity,  "  totally  different  from  the  pain  of  uterine  contrac- 
tion." Trask  said  that  she  is  conscious  of  something  having  given  way 
within  her;  "she  feels  a  tearing  or  rending  sensation,  and  in  some  in- 
stances the  noise  accompanying  the  rupture  is  heard  by  those  around 
her."  The  last  statement  is  now  generally  denied ;  Depaul  regarded  it 
as  purely  theoretical.  The  patient's  face  becomes  anxious  and  pale,  the 
skin  is  covered  with  cold  sweat,  there  are  nausea  and  vomiting,  the 
pulse  is  rapid,  threadlike,  and  irregular,  the  respiration  is  hurried,  diffi- 
cult, and  sighing,  the  sight  is  obscured,  and  there  is  ringing  in  the  ears. 
There  is  severe  pain  in  the  abdomen,  and  the  latter  notably  changes  its 
form  if  the  foetus  has  entirely  or  partially  entered  its  cavity,  or  if  there 
be  large  hemorrhage  in  it.  The  uterine  contractions  cease  in  almost  all 
cases.  Upon  vaginal  examination  generally  some  hemorrhage  is  dis- 
covered, the  presenting  part  has  receded,  or  is  replaced  by  another  pre- 
sentation, and  possibly  the  rent  can  be  at  once  felt.  In  the  580  cases 
studied  by  Jolly  the  symptoms  narrated  were  manifested  as  follows : 

Abrupt  cessation  of  contractions  was   observed  in  218  cases. 


Gradual 

Change  in  the  pulse 

Prostration 

External  hemorrhage,  slight  in  33, 

Retrocession  of  presenting  part 

Abdominal  pain 

Alteration  of  countenance    * 

Acute  pain  at  the  moment  of  rupture 


33 
179 
151 
148 
146 
133 
115 

62 


Foetal  parts  felt  immediately  under  abdominal  wall  in    77 

These  are  the  signs  almost  always  presented,  but  others  which  may 
occur  should  not  be  neglected.  Thus  a  remarkable  change  in  the  form 
of  the  abdomen  is  observed — two  tumors,  one  formed  by  the  escaped 
foetus  and  the  other  by  the  uterus,  may  be  present.  In  some  cases  the 
movements  of  the  foetus  that  have  been  active  suddenly  cease,  and  the 
sounds  of  its  heart  can  no  longer  be  heard.  Hemorrhage  may  be  ex- 
ternal, internal,  or  both  ;  Charpeutier  directs  attention  to  the  fact  that 
the  blood  may  accumulate  at  a  particular  point,  forming  a  hypogastric 


558  THE  PATHOLOGY  OF  LABOR. 

tumor.  Kiwisch,  McClintock,  Montgomery,  Paully,  Ross,  Crighton, 
and  Schatz  have  indicated  as  a  pathognomonic  phenomenon  the  occur- 
rence of  emphysema  at  the  level  of  the  hypogastric  region,  very  rapid 
sometimes,  and  which  results  from  the  penetration  of  air  through  the 
rent  and  its  diffusion  in  the  connective  tissue. 

But  the  emphysema  referred  to  can  be  present  only  in  those  cases  in  which 
the  rent  is  incomplete.  Spiegelberg  has  stated  that  the  air  either  enters  from 
without  through  the  tear  during  intra-vaginal  manipulations,  or  else  results  from 
putrefactive  changes  in  the  foetus.  This  symptom  is  always  a  very  unfavorable 
one,  all  cases  in  which  its  presence  has  been  recorded  having  proved  fatal. 

Trask  made  the  diagnostic  marks  two :  recession  of  the  presenting 
part,  and  the  ability  to  distinguish  the  limbs  of  the  foetus  beneath  the 
abdominal  parietes.  In  regard  to  the  cessation  of  the  uterine  contrac- 
tion, Jolly  found  37  in  which  this  did  not  occur,  or  was  only  temporary, 
and  in  some,  indeed,  the  contractions  retained  their  normal  force. 

PROGNOSIS.  This  is  most  unfavorable  both  for  the  mother  and  for 
the  child — especially  for  the  latter.  In  Jolly's  580  cases  only  100 
mothers  were  saved,  and  of  237  children  in  regard  to  whom  the  results 
were  stated,  only  7.5  per  cent,  were  born  alive.  The  mother  may  die 
very  suddenly  from  shock,  as  in  a  patient  of  Churchill,1  who  lived  but 
five  minutes  after  the  accident,  or  one  of  Bluff,2  who  gave  a  scream  of 
suffering  agony,  vomited,  and  died.  Instead  of  sudden  death  from 
shock,  there  may  be  rapid  death  from  hemorrhage ;  or  a  fatal  result 
may  occur  from  strangulation  of  a  coil  of  intestine  in  the  rent ;  but  the 
most  frequent  cause  of  a  fatal  termination  is  septicaemia.  In  two  cases 
reported  by  Winckel  death  was  caused  by  air  embolism.  The  same 
author  regards  the  prognosis  as  improved3  by  the  use  of  antiseptics. 

While  Jolly  gave  the  percentage  of  recoveries  as  17,  Spiegelberg 
thought  5  per  cent.,  the  result  established  by  Hugenberger,  as  being 
near  the  truth.  Zweifel  after  quoting  Trask  as  deriving  from  his 
statistics  that  the  mortality  of  expectant  treatment  was  78  per  cent., 
after  delivery  by  the  vagina  68  per  cent.,  and  after  laparotomy  24  per 
cent.,  says  these  statistics  cannot  be  correct.  The  suprisingly  small 
mortality  when  laparotomy  was  done  is  to  be  explained  by  the  fact  that 
cases  operated  upon  which  recovered  are  reported,  while  the  others  are 
passed  over,  and  by  the  relative  smallness  of  the  figures. 

TREATMENT.  This  comprises  that  advisable  in  threatened  rupture 
and  that  required  after  the  accident  has  occurred.  In  the  former  imme- 
diate delivery  is  demanded,  and  this  must  be  effected  without  additional 
stretching  of  the  cervix.  Hence,  embryotomy  is  preferable  to  version, 
for  the  introduction  of  the  hand  or  fingers  for  the  accomplishment  of 
the  latter  is  liable  to  cause  the  accident  immediately  in  such  conditions, 

i  Diseases  of  Women.  *  Siebold's  Journal,  1835. 

3  Nevertheless  this  opinion  meets  with  no  support  from  the  statistics  of  Schaffer,  "  Uber  die 
Behandlung  der  Ruptura  Uteri  mit  kompleten  Austritt  des  Kindes,"  Munich  med  Wochenschrift, 
1889.  He  states  that  of  100  laparotomies  for  this  accident,  there  were,  before  1875,  48  cases  with  31 
recoveries — 65.1  per  cent.:  antiseptic  operations,  52  cases,  19  recoveries— 36.1  per  cent. 

Freund,  Central.  1.  Gynak.,  1892 :  "  The  prognosis  of  uterine  rupture  has  not  improved  ;  the 
chief  conclusion  of  practitioners  consists  in  prophylaxis.  early  diagnosis,  and  averting  the  rupture 
by  proper  obstetrical  operations,  forceps,  turning,  and  in  their  place,  in  most  cases  better,  perfor- 
ation and  embryotomy.  Csesarean  section  only  in  case  of  absolute  indication. 

"After  rupture,  immediate  delivery,  when  possible  per  vias  naturales,  and  drainage ;  if  the  bleed- 
ing is  severe,  not  controlled  by  tampon,  if  prolapsed  and  irrestorable  loop  of  intestine,  laparotomy 
and  suture  as  soon  as  possible." 


INJURIES  OF  THE  MATERNAL  SOFT  PARTS.  559 

no  additional  strain  to  the  overstretched  tissues  being  possible  without 
this  injury  following.  If  the  child  occupies  a  transverse  position,  ern- 
bryotomy ;  if  the  head  presents  in  a  contracted  pelvis,  craniotomy  ;  or 
if  there  be  hydrocephalus,  perforation — constitute  the  treatment  advised 
by  Zweifel ;  and  he  adds  that  transverse  position,  narrow  pelvis,  and 
hydrocephalus  are  almost  the  sole  complications  of  labor,  bringing  the 
imminent  danger  of  rupture  of  the  uterus. 

After  rupture  of  the  uterus,  too,  delivery  must  be  made  as  soon  as 
possible.  If  the  woman  is  greatly  prostrated,  stimulants — especially 
hypodermatics  of  sulphuric  ether — are  indicated,  and  other  suitable 
means  employed  to  bring  about  reaction.  The  modes  by  which  delivery 
is  to  be  effected  will  depend  upon  the  position  of  the  child,  the  presen- 
tation, and  the  special  obstacle  to  labor  which  has  been  the  chief  cause 
of  the  injury.  The  child  is  either  in  the  uterus  or  in  the  abdominal 
cavity,  or  partly  in  each.  In  the  first  case,  supposing  the  head  to  pre- 
sent, the  forceps  or  the  cephalotribe  is  indicated ;  of  course,  the  head  is 
first  opened  if  the  latter  instrument  is  employed.  If  the  head  be  not 
accessible,  delivery  by  podalic  version  is  indicated.  In  the  third  case, 
still,  delivery  through  the  natural  passage  is  the  rule  if  the  part  of  the 
fretus  that  has  entered  the  abdomen  can  be  easily  brought  into  the 
uterine  cavity  and  without  increasing  the  rent.  But  if  such  restoration 
is  impossible  without  this  additional  injury  to  the  uterus,  and  in  the 
second  condition  that  has  been  stated,  abdominal  section  is  required. 
After  delivery  through  the  natural  passage,  a  3  per  cent,  solution  of 
carbolic  acid  is  used  to  wash  out  the  cavity  thoroughly,  and  a  drainage- 
tube  introduced.  Frommel,1  pursuing  this  method,  had  in  1880  three 
successful  cases,  and  the  next  year  Hecker2  reported  a  success  obtained 
in  like  manner.  Schlemer3  in  1882  had  a  case  of  rupture  in  which  a 
portion  of  intestine  prolapsed  through  the  rent,  the  fact  of  the  rent  and 
of  the  prolapse  being  ascertained  after  delivery  with  the  forceps ;  the 
bowel  was  restored,  a  drainage-tube  introduced,  an  injection  of  carbol- 
ized  water  employed  ;  the  injection  was  repeated  daily,  and  the  woman 
recovered. 

Associated  with  drainage  a  compressive  abdominal  bandage  is  em- 
ployed. The  drainage-tube  is  of  glass,  and  is  T-shaped  ;  injections  are, 
as  a  rule,  not  made  through  it  into  the  abdominal  cavity,  but  the  nozzle 
of  a  syringe  may  from  time  to  time  be  introduced  into  the  tube, 
and  fluid  drawn  out ;  the  tube  is  removed  in  about  a  week.  Zweifel, 
after  stating  that  Schroder,  Frommel,  Grafe,  Hecker,  and  Morsbach 
have  had  excellent  results  from  this  treatment,  adds  that  he  has  also 
had  in  his  clinic  a  case  that  was  successful  by  means  of  peritoneal 
drainage. 

In  a  case  of  rupture4  reported  by  Rhinestadter,  the  peritoneal  cavity 
was  washed  out  through  the  drainage-tube  with  a  1  per  cent,  carbolic 
acid  solution,  an  antiseptic  vaginal  tampon  introduced,  and  an  ice-blad- 
der applied  to  the  abdomen  over  the  rupture.  The  vaginal  dressing 
was  renewed  the  next  day,  the  drainage-tube  was  removed  four  weeks 
after  the  delivery  ;  the  woman  recovered. 

1  "  Zur  Therapie  der  Uterusruptur,"  Centralblatt  fur  Gynakol.,  1880. 

2  Ibid.,  1881.  3  Ibid.,  1882.  Op.  cit. 


560  THE  PATHOLOGY  OF  LABOR. 

Fleischman1  has  shown  the  greater  mortality  of  ruptures  of  the  anterior  por- 
tion of  the  cervix  than  of  the  posterior,  for  of  18  cases  of  the  former  all  died, 
while  of  14  of  the  latter  only  9  were  fatal,  and  he  suggests  that  in  the  former  injury 
the  abdomen  should  be  opened,  while  in  the  latter  drainage  should  be  used. 
Douglas's  cul-de-sac  presents  favorable  conditions  for  drainage,  while  the  vesico- 
uterine  does  not.  In  one  case  successfully  treated  by  drainage  the  abdominal 
cavity  was  washed  out  with  a  1  per  cent,  thymol  solution,  and  a  firm  drainage- 
tube  passed  posteriorly  into  the  cavity,  and  retained  in  position  by  a  loose  tampon 
of  iodoform  gauze. 

Piskacek2  claims  that  the  most  successful  treatment  for  complete  rupture  is 
drainage  by  iodoforni-wicking,  the  results  being  12  per  cent,  better  than  from 
laparotomy.  Seven  cases  from  Breisky's  clinic  are  given,  5  of  them  treated  by 
drainage  as  stated,  and  4  recovered.  Leopold3  emphasizes  the  importance  of 
delivering  the  child  so  that  the  mother's  life  may  be  least  endangered,  and  of 
having  especially  in  view  the  control  of  hemorrhage  by  the  promptest  treatment. 
He  attaches  more  value  to  laparotomy  than  the  previous  authority. 

Coe,  in  connection  with  a  case  of  laparo-hysterectomy  successfully  done  by 
him  for  rupture  of  the  uterus,8  believes  this  the  only  method  of  treatment  proper 
after  prolonged  and  unsuccessful  attempts  at  delivery ;  he  gives  a  table  including 
13  cases  by  different  operators,  and  the  maternal  mortality  is  a  little  more  than 
69  per  cent. 

In  case  laparotomy  is  done,  it  should  be  followed  by  hysterectomy  if 
the  hemorrhage  cannot  be  controlled  by  suturing  the  uterine  wound, 
and  a  tampon  of  iodoform  gauze. 

The  methods  of  treating  uterine  rupture,  given  by  Cholmagroff,5  are  five :  a. 
Expectant  or  antiphlogistic  ;  b,  laparotomy,  the  uterus  left,  and  the  rent  either 
sutured,  or  not ;  c,  laparotomy  with  supra-vaginal  amputation,  or  extirpation  of 
the  uterus ;  d,  drainage  of  the  uterus ;  and  e,  sutures  with,  or  without  introduc- 
tion of  iodoform  gauze. 

The  statistics  of  Merz6  show  that  drainage  counts  a  larger  number  of  successes 
than  any  other  method.  In  75  cases,  the  expectant  plan  being  pursued,  only  10 
recovered,  that  is,  14.2  per  cent. ;  the  percentage  of  recoveries  when  the  tampon 
was  used  was  40 ;  after  laparotomy,  with  or  without  suture,  or  Porro's  operation, 
48.1  per  cent,  recovered,  while  in  drainage  with  tube,  or  iodoform  material,  the 
recoveries  were  66.6  per  cent. 

R.  Braun  v.  Fernwald,  Ueber  TJterusruptur,  Vienna,  1894,  gives  19  ruptures  in 
38,000  deliveries,  that  is,  1  in  2000,  incomparably  more  rare  in  primiparse  than 
in  multiparse.  In  the  19  cases  not  one  primipara.  Age  from  24  to  44  years. 
Primary  laparotomy  in  4  cases;  2  rupture  sutured,  both  died.  In  2  Porro's  oper- 
ation, 1  fatal,  1  recovery.  In  7  cases  of  complete  rupture,  the  foetus  entirely  or 
partly  entering  the  peritoneal  cavity,  all  died.  19  ruptures,  15  complete,  4  in- 
complete, 1  complicated  with  rupture  of  the  bladder;  7  recovered,  36.84  per 
cent.  1  case  resulted  from  high  forceps  improperly  applied. 

HEMORRHAGE  AFTER  THE  BIRTH  OF  THE  CHILD.  Bleeding  sub- 
sequent to  the  delivery  of  the  child  may  arise  from  tears  at  the  vaginal 
entrance,  of  the  vaginal  wall,  or  of  the  cervix,  or  it  may  be  from  the 
interior  of  the  womb.  The  treatment  of  vulval,  vaginal,  and  cervical 
hemorrhage  has  been  presented,  and  there  remains  now  only  that 
variety  having  its  origin  in  the  uterus  to  be  considered. 

1  "Bin  Beitrag  zur  Casuistik  der  Collumdehnung  und  der  Uterusruptur,"  Zeitschrift  fur  Heil- 
kunde,  1885. 

2  See  abstract  of  Piskacek's  paper  in  the  American  Journal  of  the  Medical  Sciences.  November, 
1889. 

«  Archiv  f  Gynakol..  1889.  «  New  York  Medical  Record.  1889. 

5  Zeitschrift  f.  Geburtshtilfe  und  Gynakologie,  1894. 

6  Zur  Behandlung  des  Uterusruptur.  Arch.  f.  Gynakol.,  Band  45. 


INJURIES  OF  THE  MATERNAL  SOFT  PARTS.  561 

This  hemorrhage  is  from  the  placental  site,  and,  of  course,  is  impos- 
sible as  long  as  the  placenta  is  completely  attached,  but  may  occur  in 
case  of  partial  detachment.  It  may  occur  when  the  placenta  is  partially 
expelled,  lying  in  the  vagina,  for  example,  or  after  its  complete  expul- 
sion, an  hour  or  more  subsequent  to  the  labor. 

The  essential  cause  of  hemorrhage  is  deficient  uterine  contraction. 
The  reason  for  this  failure  may  be  previous  excessive  distentiou,  as  from 
a  plural  pregnancy,  or  from  polyhydramnios ;  or  it  may  be  too  rapid  a 
labor ;  the  uterus  suddenly  emptied  of  the  fcetus  does  not  contract  as 
promptly  as  if  the  labor  had  been  of  normal  length,  and,  on  the  other 
hand,  a  prolonged  labor  may  exhaust  the  power  of  the  uterus;  the  lia- 
bility of  albuminurics  to  post-partum  hemorrhage  has  been  previously 
stated,  while  hemophilia  is  too  obvious  a  cause  to  be  more  than  men- 
tioned. 

In  some  cases  of  uterine  fibroids  retraction  of  the  uterus  is  hindered, 
but  bleeding  will  not  result  unless  the  site  of  the  placenta  has  happened 
to  correspond  with  the  situation  of  one  of  the  tumors. 

Hemorrhage  after  the  birth  of  the  child  is  not  a  frequent,  and  in 
almost  all  cases  is  a  preventable  accident ;  it  generally  indicates  some 
sin  of  omission  or  of  commission  on  the  part  of  the  obstetrician.  Spiegel- 
berg  has  said  :  "  I  certainly  do  not  exaggerate  when  I  say  that  severe 
post-partum  hemorrhage  is  almost  without  exception  the  fault  of  the 
attendant.  The  value  of  his  services  can  be  estimated  by  the  frequency 
with  which  this  accident  occurs  in  the  labors  he  conducts." 

That  the  accident  is  not  frequent  is  shown  by  the  following  statistics  given  by 
Herman  :l  Guy's  Hospital,  1  case  of  dangerous  post-partum  hemorrhage  in  2040 
labors ;  St.  Thomas's  Hospital,  1  in  2172 ;  and  in  Prussia,  according  to  Hegar,  1 
in  3131. 

Veit2  states  that  since  Diihrssen  recommended  packing  the  uterus  with  iodo- 
form  gauze,  he  has  sought  to  ascertain  how  often  atonic  bleeding  occurs.  In 
analyzing  the  statistics  of  20,378  births  given  in  seventeen  years  in  the  Charite- 
Annalen,  the  frequency  of  atony  varies  from  0  to  25  :  in  all  there  were  only  two 
deaths  from  atonic  bleeding.  Further,  Veit  combining  these  statistics  of  births 
with  those  of  Ahlfeld,  Winckel,  Derselbe,  and  of  Chiari,  Braun  and  Spath,  and 
Hecker,  making  47,765  cases,  finds  there  were  only  five  fatal  cases  of  atonic  hemor- 
rhage. Incidentally,  it  is  stated  by  Veit  that  in  one  of  the  fatal  cases  packing 
with  iodoform  gauze  was  employed ;  a  similar  case  is  given  by  Strassman. 

SYMPTOMS.  There  is  generally  observed  an  unusual  frequency  of 
the  pulse,  but  this  increase  is  possibly  only  slight ;  nevertheless  its  occur- 
rence should  put  the  practitioner  upon  his  guard,  even  though  he  finds 
the  uterus  at  the  time  nearly  normal  in  size  and  in  firmness.  The  pa- 
tient probably  complains  of  great  thirst,  and  she  is  somewhat  restless. 
But,  it  may  be  without  any  premonitory  symptoms,  the  flow  of  blood  is 
suddenly  manifest,  trickling  through  or  down  by  the  side  of  the  bed  to 
the  floor ;  the  discharge  may  be  so  rapid  and  great  that  it  is  appropri- 
ately called  flooding,  a  flood  upon  which  the  patient's  life  is  swiftly 
borne  away  unless  proper  measures  are  promptly  used ;  now  she  is 
usually  restless,  and  her  arms  rise  and  fall,  thrown  to  this  side  and  to 
that  in  a  sort  of  aimless  way,  and  agony  of  despair  ;  her  respiration  is 

1  British  Medical  Journal,  1892. 

2  Zur  Pathologie  und  Therapie  der  Blutungen  unmittlebar  nach  der  Geburt.    Zeits.  f.  Geburts  und 
Gynakol.,  1894. 

36 


562  THE  PATHOLOGY  OF  LABOR. 

sighing,  and  she  wants  fresh  air,  and  possibly  she  complains  of  the  dark- 
ness of  the  room,  exclaiming,  "  I  can't  see !"  while  a  deathlike  pallor  is 
upon  her  face.  You  put  your  finger  upon  her  pulse ;  it  is  frequent, 
thready,  intermittent ;  your  hand  upon  her  abdomen,  and  the  small 
hard  uterine  globe  is  no  longer  felt,  but  there  is  excessive  abdominal 
distention,  and  it  is  often  difficult  or  impossible  to  define  the  boundaries 
of  the  uterus — a  relaxed  sac  filled  with  blood. 

TREATMENT.  If  ever  there  is  one  time  more  than  any  other  in  the 
obstetrician's  life  when  he  needs  to  be  calm  and  collected  and  to  put 
forth  prompt  and  intelligent  action,  it  is  when  he  is  brought  face  to 
face  with  post-partum  hemorrhage. 

In  addition  to  lowering  the  patient's  head  and  the  administration  of 
stimulants  and  of  hypodermatic  injections  of  sulphuric  ether,  etc.,  appli- 
cable in  other  cases  of  bleeding  with  consequent  exhaustion,  we  use  direct 
means  to  arrest  the  bleeding.  First  of  these  is  uterine  compression. 
The  usual  method  of  doing  this  is  to  grasp  the  uterus  through  the  ab- 
domen with  one  hand,  while  the  other  is  introduced  into  the  uterine 
cavity  in  order  that  its  presence  may  evoke  uterine  contraction.1  Pos- 
sibly, too,  the  placenta  may  still  be  in  the  uterus,  either  free  or  par- 
tially attached ;  in  the  latter  case  the  fingers  are  used,  as  the  uterus  les- 
sens in  size,  to  detach  it,  and  in  either  case  to  remove  it  from  the  uterus 
at  the  proper  time.  Probably  the  uterus  is  very  sensitive  when  pressed 
by  the  abdominal  hand,  but  this  arises  from  its  great  distention,  and  as 
soon  as  the  organ  is  emptied  the  excessive  sensibility  ceases ;  possibly 
the  uterus  cannot  be  felt  at  first  by  this  hand — it  is  so  relaxed  that  it 
has  lost  its  form — but  then  so  much  the  more  necessity  for  prompt 
action. 

Should  this  means  fail  in  arresting  the  hemorrhage,  compression  of 
the  uterus,  placed  in  a  position  of  anteflexion,  may  be  employed.  Zweifel 
says  it  ought  to  be  possible  to  stop  every  atonic  hemorrhage  by  energetic 
use  of  this  treatment.  In  it  pass  two  fingers  into  the  posterior  cul-de- 
sac,  and  press  the  cervix  forward,  while  the  other  hand,  upon  the  ab- 
domen, is  made  to  press  upon  the  fundus  posteriorly,  bringing  it  also 
forward  as  shown  in  the  accompanying  illustration. 

Compression  of  the  abdominal  aorta  may  be  made  with  the  fingers  of  the  left 
hand,  the  obstetrician  being  upon  the  patient's  right  side ;  the  abdominal  wall 
is  depressed  just  above  the  uterus  and  a  little  to  the  left  of  the  median  line  until 
the  pulsations  of  the  vessel  are  felt,  and  then  slight  pressure  with  the  first  three 
fingers  will  arrest  the  current.  An  assistant  will  be  needed,  for  the  fingers  be- 
come too  tired  after  twenty  or  thirty  minutes  to  maintain  efficient  compression. 
Compression  of  the  abdominal  aorta  was  probably  first  advocated  by  Rudiger,  a 
practitioner  of  Tubingen,  in  1797.  His  method  was  with  the  hand  introduced 
into  the  uterus,  pressing  through  its  posterior  wall.  Ulsamer  in  1825  introduced 
the  method  of  pressure  through  the  abdominal  wall,  and  it  received  the  strong 
indorsement,  from  personal  experience,  of  Siebold  and  of  Baudelocque.  Gros* 
has  reported  nine  cases  of  puerperal  hemorrhage  in  which  it  was  successfully 
employed.  Zweifel  holds — this  objection  has  been  made  by  Jacquemier  and 
others — that  it  is  impossible  to  cut  off  by  this  means  all  the  blood-supply  to  the 
uterus,  because  the  spermatic  arteries  pass  off  from  the  aorta  above  the  part  com- 

1  Nevertheless,  Veit  (op.  cit.)  holds  that  never  in  the  first  hours  is  the  hand  to  be  passed  into  the 
genital  canal  in  treating  atony.  He  further  holds  that  manual  detachment  of  the  placenta  is  an 
entirely  superfluous  operation. 

*  De  la  Compression  de  1'Aorte  dans  les  Hemorrhages  apres  1'Accouchement. 


INJURIES  OF  THE  MATERNAL  SOFT  PARTS. 


563 


pressed,  and  that  the  chief  benefit  is  in  preventing  cerebral  anaemia,  in  this  re- 
spect being  upon  the  same  level  as  bandaging  the  limbs,  or  what  is  known  as 
auto  transfusion. 

Uterine  contractility  has  been  in  some  cases  evoked  by  flapping  the 
abdominal  wall  with  a  wet  towel,  by  pouring  cold  water  from  a  height 
upon  the  exposed  abdomen,  by  the  application  of  ice  to  it,  by  the  intro- 
duction of  pieces  of  ice  into  the  vagina  or  into  the  uterus,  or  by  the 
injection  of  cold  water  into  each.  In  recent  years,  however,  the  general 
preference  has  been  for  injecting  the  uterus  with  hot,  rather  than  cold 
water,  the  former  being  more  efficient  than  the  latter  in  producing  per- 
manent contraction,  and  stimulating  rather  than  depressing.  The  water 
should  have  a  temperature  of  not  less  than  105°  F.,  and  an  irrigator 
used  for  its  introduction,  rather  than  a  pump. 

FIG.  218. 


ARRESTING  HEMORRHAGE  BY  COMPRESSION  OF  THE  UTERUS  IN  A  POSITION  OF 
ANTEFLEXION.    (ZWEIFEL.) 

The  application  of  vinegar  to  the  interior  of  the  uterus  was  probably  first  ad- 
vised by  Leroux1  in  1776.  Since  then  many  obstetricians  have  regarded  this 
remedy  as  of  very  great  value.  Dr.  Penrose,2  for  example,  states  that  he  has 
been  using  it  alone  as  his  last  resort,  both  in  hospital  and  private  practice,  in 

1  Observations  sur  16s  Pertes  du  Sang  des  Femmes  en  Couches. 

2  Transactions  of  the  American  Gynecological  Society,  vol.  iii. 


564  THE  PATHOLOGY  OF  LABOR. 

many  apparently  desperate  cases  of  post-partum  hemorrhage,  and  invariably 
with  successful  results.  His  method  is  the  following :  "  I  pour  a  few  tablespoon- 
fuls  into  a  vessel ;  dip  into  it  some  clean  rag  or  a  clean  pocket-handkerchief.  I 
then  carry  the  saturated  rag  with  my  hand  into  the  uterus,  and  squeeze  it;  the 
effect  of  the  vinegar  flowing  over  the  sides  of  the  cavity  of  the  uterus  is  magical. 
The  relaxed  and  flabby  uterine  muscle  instantly  responds."  Similar  stimulating 
applications  have  been  successfully  made  to  the  interior  of  the  uterus— e.  </., 
whiskey.  Betz1  succeeded  in  arresting  post-partum  bleeding  by  introducing  into 
the  uterus  a  sponge  upon  which  chloroform  had  been  poured ;  and  it  has  been 
claimed  that  this  agent  acts  by  a  powerful  excitement  of  the  walls  of  the  vessels 
either  directly  or  through  the  vasomotors,  and  that  it  is  incomparably  more 
energetic  than  vinegar  similarly  applied. 

A  styptic  solution  of  one  of  the  iron  salts  has  been  employed  with  success. 
There  are  three  ways  in  which  such  a  solution  is  used — by  injection,  by  swab- 
bing, and  by  tamponing.  Dr.  Robert  Barnes  has  been  the  especial  advocate  of 
the  first.  The  following  quotation'2  gives  the  formula  for  the  iron  styptic  em- 
ployed by  him  and  his  method  of  using  it :  "Solid  ferric  chloride,  ^j,  dissolved 
in  ^x  of  water,  or  the  liquor  ferri  perchloridi  (Br.  Ph.)  gjss,  water  Svijss.  The 
rules  in  using  it  are :  (1)  be  sure  that  the  uterus  is  empty  of  placenta,  blood,  and 
clots  ;  (2)  compress  the  body  of  the  uterus  by  the  hand  during  the  injection ;  (3) 
have  two  basins  at  hand,  one  containing  hot  water,  the  other  the  ferric  solution  ; 
pump  water  well  through  the  syringe — a  good  Higginson's  will  do— so  as  to 
expel  air;  then  pass  the  uterine  tube  into  the  uterus,  and  inject  first  hot 
water,  so  as  to  wash  out  the  cavity  and  give  a  last  opportunity  for  evoking 
diastaltic  contraction  ;  then  shift  the  receiving-end  of  the  syringe  into  the  ferric 
solution,  and  slowly,  gently  inject  about  seven  or  eight  ounces,  carefully  keeping 
up  steady  pressure  on  the  uterus  throughout  and  afterward." 

Dr.  Wynn  Williams3  has  advised  applying  the  iron  solution  by  means  of  a 
sponge  to  the  interior  of  the  uterus.  He  directs  pouring  some  of  the  tincture  of 
the  perchloride  of  iron  into  a  sponge,  which  is  then  passed  into  the  hollow  of 
the  hand  already  in  the  uterus,  clots  from  the  latter  having  been  removed,  and 
then  the  walls  of  the  uterus  are  thoroughly  sponged  over. 

Tamponing  the  uterine  cavity  with  cotton  that  has  been  dipped  in  a  solution 
of  the  chloride  of  iron  is  regarded  by  Zweifel  as  only  a  final  resort  when  all  other 
appropriate  means  have  been  vainly  tried ;  and  he  refers  to  one  case,  the  only 
one  in  which  he  tried  this  heroic  treatment,  that  recovered  with  very  slight 
elevation  of  temperature.  He  directs  two  or  three  tampons  to  be  dipped  in  a 
solution  of  chloride  of  iron,  and  then  pressed  directly  upon  the  placental  site, 
while  external  pressure  is  simultaneously  made  upon  the  uterus ;  if  the  bleeding 
still  continues,  the  application  is  repeated  until  it  stops.  He  prefers  this  treat- 
ment to  injections  of  an  iron  solution,  stating  that  he  has  seen  one  patient  die 
after  such  injection,  and  another  recover  after  the  tampon. 

Diihrssen4  recommends,  in  atonic  hemorrhage,  tamponing  the  uterine  cavity 
with  iodoform  gauze,  and  his  recommendation  has  been  followed  by  many  others 
The  gauze  is  prepared  by  dipping  it  in  a  20  per  cent,  iodoform  solution ;  also 
powdered  iodoform  is  sprinkled  on  it.  Three  strips  the  width  of  the  hand  and 
three  metres  in  length  will  be  used ;  the  cervix  is  seized  with  forceps,  and  drawn 
down  to  the  vulva,  thus  exposed  to  sight,  or  if  not  the  finger  is  used  as  a  guide ; 
one  end  of  a  strip  of  gauze,  thirty  centimetres  long,  is  taken  up  by  forceps,  and 
carried  into  the  uterine  cavity ;  after  placing  one  hand  externally  over  the 
fundus,  the  end  of  the  gauze  is  carried  up  to  the  fundus  internally,  next  a  fold 
of  the  gauze  laid  over  the  first,  and  thus  successive  layers,  like  the  folds  of  a 
closed  fan  ;  the  second  and  then  the  third  strip  are  similarly  applied,  and  the 
uterus  is  soon  filled,  and  the  organ  contracts  in  consequence  of  the  contact  of  a 
foreign  body  with  its  mucous  membrane.  The  tampon  does  not  cause  suffering  ; 
at  the  end  of  twenty-four  hours  it  is  removed,  and  there  is  no  trace  of  decompo- 
sition ;  next,  the  uterus  is  washed  out  with  a  solution  of  salicylic  acid. 

Kaltenbach  has  spoken  of  the  difficulty  of  using  the  tampon  if  the  uterus  is 

1  Revue  Medico-cnirurgicale  des  Maladies  des  Femmes,  1886. 

2  Obstetric  Medical  Society's  Transactions,  vol.  xl.  p.  292. 

3  London  Obstetrical  Society's  Transactions,  vol.  xi.  1870. 
<  Archives  de  Tocologie,  1887. 


INJURIES  OF  THE  MATERNAL  SOFT  PARTS.  565 

relaxed ;  often  the  organ  remains  incompletely  tamponed,  and  the  hemorrhage 
is  concealed. 

Herman  severely  criticises  the  gauze  method,  stating  that  we  must  judge  the 
effect  of  it  rather  by  the  fewness  of  the  failures  than  by  the  number  of  apparent 
successes ;  he  regards  the  treatment  as  neither  certain  nor  safe,  and  finally  con- 
demns it  as  unphysiological.  Some  cases  in  which  the  tampon  failed  are  given 
by  him,  and  several  others  might  be  added.  Time  is  lost  in  applying  the 
means,  and  some  hemorrhage  during  the  application  is  inevitable,  while  directly 
the  opposite  is  true  in  bimanual  compression  of  the  uterus. 

Undoubtedly  the  tampon  has  been  employed  in  many  cases  in  which  the 
hemorrhage  was  trifling,  and  hence  many  of  its  apparent  successes. 

Kortiim1  objects  to  iodoform  gauze  on  the  ground  of  danger  of  poisoning,  and 
regards  gauze  that  has  been  dipped  in  a  2  to  3  per  cent,  creolin  mixture  as  in 
every  respect  preferable. 

Schroder  especially  directed  attention  to  paralysis  of  the  place  of  placental 
insertion  as  a  cause  of  post-partum  hemorrhage,  a  condition  first  pointed  out  by 
Engel,  in  1 840  ;  and  he  urged  the  importance  of  large  doses  of  ergot,  and,  in  the 
worst  cases,  injection  of  a  solution  of  chloride  of  iron  to  arrest- the  bleeding. 

Schauta2  refers  to  extirpation  of  the  uterus  by  abdominal  section  as  an  opera- 
tion not  to  be  thought  of  in  private  practice,  but  does  speak  favorably  of  the 
proposition  of  Kocks,  to  invert  the  uterus,  then  encircle  the  organ  with  a  rubber 
tube,  or  with  a  bandage  of  iodoform  gauze,  thus  instantly  arresting  the  hemor- 
rhage; after  six  hours  the  bandage  is  removed,  and  the  hemorrhage  having 
stopped  the  organ  is  restored.  Neither  of  these  methods  is  to  be  advised. 

Auto-transfusion  has  upon  theoretical  grounds  and  from  experience 
somewhat  to  recommend  it.  By  bandaging  the  members  so  that  the 
blood  which  they  contain  is  pressed  out,  and  thus  contributes  to  sus- 
taining vital  functions,  at  times  imminent  death  may  be  averted.  But, 
on  the  other  hand,  death  may  be  thus  invited,  for  fatal  pulmonary 
embolism  has  followed  its  employment. 

HYPODEEMOCLYSIS.  Grenser,3  and  some  others,  advocate  the  subcutaneous 
introduction  of  a  solution  of  chloride  of  sodium.  Munchmeyer4  regards  it  as 
free  from  danger,  thus  differing  from  intravenous  injection,  and  states  that  it  is 
not  painful.  The  quantity  required  will  be  one  litre,  the  strength  of  the  solu- 
tion 6  to  1000 ;  it  must  be  sterilized,  and  the  apparatus  required  for  its  intro- 
duction are  a  glass  funnel  of  medium  size,  a  rubber  tube,  and  a  fine  needle  ;  the 
solution  has  the  temperature  of  the  body,  and  the  parts  of  election  into  which  it 
is  introduced  are  the  subclavicular  and  the  interscapular  regions. 

Runge  states  that  transfusion  of  blood  is  completely  and  justly  displaced  by 
the  infusion  of  the  physiological  salt  solution.  The  method  has  been  referred 
to  on  page  405. 

SECONDARY  HEMORRHAGE.  The  subject  of  hemorrhage  in  connec- 
tion with  labor  cannot  be  dismissed  without  briefly  referring  to  a  form 
of  this  disorder  occurring  one  or  more  days  after  delivery  during  the 
puerperal  period,  and  which  is  commonly  called  secondary.  The  most 
frequent  cause  is  the  retention  of  fragments  of  placenta  or  of  mem- 
branes ;  a  placenta  succenturiata  has  in  some  cases  given  rise  to  danger- 
ous hemorrhage. 

Several  cases  have  been  reported  in  which  the  retention  of  a  blood-clot  has 
caused  flooding.  Ordinarily,  the  uterus  is  adequate  to  the  expulsion  of  clots 
that  may  form  in  its  cavity,  but  sometimes,  this  expulsion  failing,  the  clot  in- 
creases in  size ;  the  lochial  discharge  is  scanty  and  serous ;  the  uterus,  though 

1  Centralblatt  f.  Gynakol.,  1887-89.  2  Die  Behandlung  der  Blutungen  post  partum. 

s  Centralblatt  f.  GynSkol.,  1889.  <  Archiv  f.  GynSkol.,  1889. 


566  THE  PATHOLOGY  OF  LABOR. 

notably  increased  in  size,  is  firm  and  resistant ;  for  a  time  the  clot  acts  as  a 
tampon  pressing  upon  the  placental  site,  and  thus  prevents  hemorrhage.  After 
some  days  the  coagulum  spontaneously  breaks  up,  the  protecting  pressure  is  at 
once  withdrawn  from  the  open  vessels  at  the  placental  site,  and  a  hemorrhage 
which  is  perilous  or  may  be  instantly  fatal  at  once  follows.  In  some  instances 
a  uterine  fibroid  or  polypus  has  been  the  cause  of  secondary  puerperal  hemor- 
rhage. Mental  emotion  has  in  several  instances  produced  it.  Lactation,  sexual 
intercourse,  too  early  assumption  of  the  erect  position  or  engaging  in  household 
duties,  the  influence  of  malarial  poisoning,  and  certain  displacements  of  the 
uterus  have  been  mentioned  as  causes.  Among  very  rare  cases  may  be  stated 
one  reported  by  Hewitt,1  of  fatal  hemorrhage  the  sixth  week  after  labor  from 
traumatic  aneurism  of  the  uterine  artery,  and  one  by  Johnson2  and  Sinclair,  in 
which  death  occurred  the  fourth  day  following  delivery  from  rupture  of  a  uterine 
thrombus. 

In  regard  to  special  treatment  of  secondary  hemorrhage,  the  im- 
portance of  removing  any  foreign  body,  as  a  fragment  of  the  placenta 
or  clot,  from  the  uterus  is  to  be  borne  in  mind.  In  regard  to  the  method 
of  emptying  the  uterus  of  a  mass  of  coagulated  blood  which  distends 
the  organ,  the  fingers,  Pajot's  curette,  or  a  stream  of  carbolized  water 
may  be  employed.  During  this  removal  external  compression  of  the 
uterus  is  important  in  order  to  secure  retraction  of  the  organ  and  thus 
prevent  hemorrhage.  The  cases  are  rare  in  which  the  uterus  is  not  able 
to  empty  itself,  but  certainly  some  occur  in  which  direct  means  must  be 
used  for  the  purpose,  and  thereby  possibly  a  fatal  hemorrhage  may  be 
prevented ;  thus  Contamiu3  found,  in  6  out  of  56  cases  of  secondary 
hemorrhage,  an  intrauterine  coagulum  the  cause. 

Ergot  will  most  probably  be  required  in  these  cases,  and  often  the  use 
of  hot  water  injections  will  be  advisable. 

INVERSION  OF  THE  UTERUS.  Inversion  of  the  uterus  is  the  gravest 
possible  displacement  of  this  organ.  Fortunately,  it  is  not  a  frequent 
accident,  statistics  showing  that  it  does  not  occur  oftener  than  once  in 
one  hundred  and  forty  thousand  deliveries.  An  inverted  uterus  has 
been  compared  to  the  finger  of  a  glove  turned  inside  out ;  the  disorder 
has  been  described  as  a  hernia  of  the  uterus  through  the  os ;  Pare  ap- 
plied the  term  "  perversion  "  to  it,  a  word  which  Crosse  in  his  well- 
known  monograph4  used  to  designate  the  final  degree  of  this  displace- 
ment;  if  the  inversion  be  complete,  the  simplest  statement  of  the 
condition  is  :  the  uterus  is  upside  down  and  inside  out. 

Denuce5  attributes  the  first  recognition  of  inversion  of  the  uterus  to  Hippoc- 
rates, who  also  directed  a  plan  for  its  restoration ;  he  quotes,  too,  a  passage  from 
Aretseus,  who  not  only  described  the  accident,  but  also  referred  to  traction  upon 
the  cord  as  one  of  the  causes,  this  traction  being  made  in  an  effort  to  remove 
an  attached  placenta ;  so,  too,  subsequent  great  lights  of  ancient  medicine,  as 
Soranus,  Moschion,  Galen,  Paul,  of  jEgina,  and  others,  have  referred  more  or 
less  distinctly  to  inversion  of  the  uterus  as  an  accident  of  childbirth. 

Two  conditions  of  the  uterus  are  necessary  in  order  that  it  can  be- 
come inverted — increase  of  the  cavity  and  relaxation,  either  general  or 

i  London  Obstetrical  Society's  Transactions,  vol.  ix.  2  Practical  Midwifery. 

*  Etude  sur  les  HSmorrhagies. 

4  "  Essay  upon  Uterine  Inversion."    Transactions  of  the  Provincial  Medical  and  Surgical  Associ- 
tion,  London,  1844  and  1847. 

5  Traits  clinique  de  1'Inversion  uterine,  Paris,  1883. 


INJURIES  OF  THE  MATERNAL  SOFT  PARTS. 


567 


local,  of  the  walls.     These  conditions  are  presented  by  the  uterus  in 
pregnancy  and  in  labor,  but  they  may  also  occur  if  the  uterus  be  dis- 


FlG.  219. 


FIG.  220. 


FIG.  221. 


THREE  DEGREES  OF  INVERSION.    (After  CROSSE.) 

1,  depression  ;  2,  introversion ;  3,  complete  inversion  ;  a,  fundus  of  uterus  ;  66,  cavity  of  uteri 
receiving  inverted  fundus ;  c,  vagina  ;  dd,  mouth  of  inverted  portion. 

tended  from  other  cause  than  an  ovum  ;  as,  for  example,  by  a  polypus. 
In  400  cases  of  this  accident  collected  by  Crosse,  only  50  occurred  inde- 

FIG.  222. 


INVERSION  OF  THE  UTERUS,  FROM  SPECIMEN  IN  MUS£E  DUPUYTREN.     (After  CROSSE.) 
a,  vagina ;  6,  inverted  fundus,  incised  at  c  to  show  its  cavity ;  d,  point  of  inversion,  with  round 
ligaments,  tubes,  and  ovarian  ligaments  drawn  in  ;  ee,  ovaries ;  ff,  flmbriated  ends  of  tubes ;  gg, 
round  ligaments  ;  h,  cervix  covered  by  peritoneum. 

pendeutly  of  pregnancy.    Most  of  the  350  thus  connected  with  gestation 
occurred  at  its  conclusion,  only  a  very  few  happening  after  abortion. 


568  THE  PATHOLOGY  OF  LABOR 

In  this  article  the  inversion  occurring  in  connection  with  childbirth, 
and  its  treatment,  will  alone  be  considered. 

The  uterus  when  inverted  forms  a  cavity  lined  with  serous  membrane 
and  opening  into  the  abdomen  ;  according  to  the  degree  and  the  recency 
of  the  inversion,  this  newly  formed  cavity  will  contain  part  of  the  ovi- 
ducts, of  the  round  and  of  the  broad  ligaments,  and  in  some  in- 
stances the  ovaries  and  loops  of  intestine.  Three  degrees  of  inversion 
are  described.  In  the  first  the  fundus  is  depressed,  a  cup-like  cavity 
being  formed,  which  may  be  felt  from  the  abdominal  wall ;  in  the  sec- 
ond the  fuudus  has  descended  to  the  internal  os  uteri,  the  entire  body 
of  the  organ  thus  participating  in  the  displacement ;  in  the  third  degree 
the  fundus  and  the  body  have  passed  out  of  the  os ;  in  the  last  case  the 
uterus  may  pass  out  of  the  vulva  and  be  external,  the  vagina  neces- 
sarily undergoing  partial  inversion,  and  then  there  is  prolapse  of  the 
inverted  uterus. 

CAUSES  OF  UTERINE  INVERSION.  Remembering  that  the  first  de- 
gree of  this  disorder  consists  in  a  depression  of  the  uterine  wall  at  its 
upper  portion,  a  cupping  of  the  fundus,  as  it  is  sometimes  called  ;  this 
depression  may  result  from  intra-uterine  traction  or  from  extra-uterine 
pressure.  Either  traction  or  pressure  may  be  spontaneous  or  artificial ; 
the  resulting  inversion  may  be  complete  or  incomplete. 

Pulling  upon  the  cord  for  the  delivery  of  the  placenta  was,  as  has 
been  previously  stated,  recognized  by  Aretseus  as  one  of  the  causes  of 
uterine  inversion,  and  probably  it  is  the  most  frequent  cause.  The 
skepticism  as  to  this  being  common,  manifested  by  one  of  the  wisest  of 
American  gynecologists,  Dr.  Emmet,  upon  the  ground  that  such  de- 
livery of  the  placenta  is  so  common  on  the  part  of  ignorant  midwives, 
and  therefore  the  accident  ought  to  be  much  more  frequent,  is  not  well 
founded.  Certain  conditions  must  be  present  in  order  that  traction 
upon  the  cord  may  invert  the  uterus,  and  among  these  are  a  firm  attach- 
ment of  the  placenta,  the  site  of  that  attachment  the  fundus  or  its  vicinity, 
and  uterine  relaxation  ;  the  usual  absence  of  one  or  more  of  these  con- 
ditions explains  the  rarity  of  the  accident. 

One  of  the  most  remarkable  cases  of  uterine  inversion  caused  by  pulling  upon 
the  cord  has  been  recorded1  by  an  American  physician,  Dr.  Woodson,  of  Ken- 
tucky :  A  negress  four  months  pregnant  was  taken  with  severe  uterine  pains  in 
a  bath ;  she  succeeded  in  seizing  the  foetus  and  dragged  it  out,  inverting  the 
uterus.  Relative  or  absolute  shortness  of  the  cord  has  in  several  instances  been 
followed  in  spontaneous  delivery  by  inversion  of  the  uterus.  Baudelocque  has 
given  two  examples.  So,  also,  delivery  with  the  forceps  has,  in  a  similar  condi- 
tion of  the  cord,  caused  the  accident.  Illustrative  cases  are  given  by  Levret  and 
Bockendal.2  The  cord  may  be  normal  in  length,  but  from  the  unusual  position 
occupied  by  the  woman  during  the  expulsion  of  the  child  the  uterus  may  be  in- 
verted by  the  weight  of  the  child  dragging  upon  or  suspended  by  the  cord.  Daillez 
reported  the  following  case :  A  girl  eighteen  years  old,  near  her  labor,  was  driven 
from  home  by  her  her  father  ;  she  took  refuge  in  the  house  of  a  friend,  and  soon 
felt  the  pains  of  childbirth.  An  accoucheur  called  to  see  her  thought  that  she 
was  suffering  from  false  pains,  and  went  away ;  upon  his  return  he  found  her 
dying,  the  uterus  completely  inverted  and  hanging  between  her  thighs ;  he 
learned  that  the  unfortunate  girl  was  delivered  standing,  her  elbows  resting  upon 

1  American  Journal  of  the  Medical  Sciences,  1860.  2  See  Denuce. 


INJURIES  OF  THE  MATERNAL  SOFT  PARTS.  569 

the  back  of  a  chair;  the  child  suddenly  escaped  and  the  cord  was  ruptured.  The 
traction  upon  the  uterine  wall  may  be  made  by  the  partially  detached  placenta 
and  clots  of  blood ;  thus,  Kormanu1  quotes  a  case  from  Dr.  Camillo  Fiirst  in 
which  the  accident  occurred  from  the  weight  of  a  mass  of  blood  resulting  from 
a  partial  separation  of  the  placenta  retained  by  adherent  membranes. 

The  inversion  may  be  caused  by  extra-uterine  pressure.  This  pres- 
sure may  be  manual  or  abdominal.  The  former  may  be  made  in  im- 
proper efforts  exercised  to  effect  the  delivery  of  the  placenta  by  the 
so-called  Crede's  method.  But  abdominal  pressure,  there  being  no 
manual  interference  whatever,  may  cause  the  accident. 

Denuce  quotes  from  Galen  the  following  remarkable  passage,  showing  that  he 
recognized  this  cause  of  uterine  inversion :  "  Under  the  influence  of  the  power 
of  expulsion,  which  is  the  opposite  of  the  power  of  retention,  of  which  we  have 
spoken,  the  mouth  of  the  wound  opens,  and  the  entire  fundus  of  this  organ  so 
far  as  possible  approaches  it,  pushing  the  foetus  out.  At  the  same  time  as  the 
fundus  of  the  uterus,  the  parts  that  surround  it,  the  abdominal  walls,  which  are 
the  external  walls  of  the  instrument  of  expulsion  regarded  in  its  whole,  pushing 
by  the  action  of  all  their  forces,  strongly  clasp  the  foetus  and  force  all  out.  This 
part  of  the  action,  which  is  under  the  woman's  control,  resides  not  in  the  uterus, 
but  in  the  abdominal  muscles,  which  come  to  her  aid  as  they  do  in  defecation 
and  in  urination.  Also  in  some  women,  when  this  expulsive  power  is  exerted 
immoderately,  the  violent  pains  may  drive  out  the  uterus  itself.  The  accident 
is  entirely  similar  to  that  which  occurs  in  struggle  or  combat,  when  one  of  the 
contestants,  forcing  the  other  backward,  throws  him  upon  the  ground,  at  the 
same  time  falling  on  him.  Thus  the  uterus,  when  it  violently  expels  the  foetus, 
may  itself  be  at  the  same  time  precipitated  without,  especially  if  the  ligaments 
which  fasten  it  in  the  basin  are  previously  relaxed." 

Paralysis  of  the  placental  site  or  general  atony  of  the  uterus  is  a  con- 
dition which  permits  inversion  of  the  uterus  by  abdominal  pressure. 
Supposing  the  portion  of  the  uterus  corresponding  with  the  place  of 
placental  attachment  to  be  paralyzed,  there  may  follow,  either  with  or 
without  abdominal  strain,  dropping  down  of  this  part  into  the  grasp  of 
non-paralyzed  but  active  muscular  walls  of  the  uterus  ;  these,  therefore, 
receiving  the  introcedeut  mass  actively  contracting,  may  make  the  in- 
version complete.  John  Hunter,  in  describing  an  inversion  of  the 
uterus  caused  by  a  polypus,  observed  :  "  I  conceive  the  contained  or  in- 
verted part  becomes  an  adventitious  or  extraneous  body  to  the  contain- 
ing, and  it  continues  its  action  to  get  rid  of  the  inverted  part,  similar 
to  an  intussusception  of  the  intestine."  Barnes,  in  referring  to  Hunter's 
description,  states  that  it  contains  the  germ  of  most  subsequent  theo- 
retical explanations. 

The  most  recent  study  of  uterine  inversion  is  that  by  Beckman.2  His  investi- 
gation of  100  cases  of  this  accident  show  that  more  than  one-half  of  the  inver- 
sions were  spontaneous,  and  only  one-fifth  were  caused  by  pulling  upon  the  cord ; 
seven  of  these  occurred  in  one  to  five  days  after  labor. 

SYMPTOMS  AND  DIAGNOSIS.  Pain,  shock,  and  hemorrhage  are  the 
chief  symptoms  of  sudden  and  complete  inversion  of  the  uterus.  The 
woman  in  many  cases  cries  out  with  the  suffering ;  she  may  declare,  if 

1  Op.  cit.  2  Zur  Aetiologie  des  Inversio  Uteri  post  partura  :  Z.  f.  G.  und  G.,  1895. 


570  THE  PATHOLOGY  OF  LABOR. 

the  inversion  occurs  rapidly  as  a  consequence  of  traction  upon  the  cord, 
that  her  intestines  are  being  torn  away.  The  shock  is  partly  the  expres- 
sion of  this  acute  suffering,  partly  the  sudden  withdrawal  from  the 
abdomen  of  one  of  its  largest  organs ;  and  should  serious  hemorrhage 
occur,  the  loss  of  blood  contributes  to  it.  The  face  is  pale,  the  expres- 
sion anxious,  the  pulse  frequent  and  feeble,  the  limbs  cool,  and  there 
may  be  vomiting  and  also  convulsions.  The  hemorrhage  may  be  slight, 
for  if  the  placenta  be  entirely  adherent  to  the  uterus  there  can  be  no 
considerable  bleeding ;  if,  however,  it  be  completely  or  partially  de- 
tached, the  flow  may  be  very  profuse  and  prove  fatal  in  a  short  time. 
But  there  may  be  little  or  no  bleeding,  yet  the  collapse  be  profound. 
"Symptoms  of  incarceration  may,  and  frequently  do,  arise  when  coils 
of  intestine  have  entered  the  funnel  formed  by  the  inverted  uterus  and 
have  become  compressed."1 

Abdominal  examination  shows  the  absence  of  the  uterine  globe,  and 
a  tumor  occupying  the  vagina,  or  even  chiefly  projecting  from  the  vulva, 
is  found.  This  tumor  may  have  the  placenta  still  attached,  and  then 
an  error  in  diagnosis  is  impossible.  If  the  placenta  has  been  cast  off, 
the  obstetrician  possibly  doubts  whether  the  tumor  found  in  the  vagina 
or  at  the  vulva  be  an  inverted  uterus  or  a  polypus,  retention  of  urine 
being  a  common  consequence  of  inverted  uterus,  and  a  distended  bladder 
may  simulate  the  uterus ;  therefore,  let  him  who  has  not  witnessed  the 
accident,  but  who  first  sees  the  condition  hours  or  a  day  or  two  after 
its  occurrence,  begin  by  using  a  catheter.  No  confusion  from  this  cause, 
and  no  error  in  diagnosis  thence  derived ;  a  bimanual  examination,  the 
impossibility  of  passing  a  uterine  sound  into  the  uterine  cavity  if  the 
organ  be  inverted,  and  ascertaining  that  the  point  of  a  sound  passed 
into  the  bladder  may  be  felt  in  the  median  line  by  two  fingers  in  the 
rectum  too  distinctly  to  suppose  that  the  uterus  intervenes,  will  leave 
no  doubt  in  the  mind  of  the  careful  examiner.  I  have  been  called  to 
three  cases  of  inversion  of  the  uterus,  and  I  have  not  in  one  of  them 
found  the  organ  the  seat  of  intermittent  contractions  ;  yet  such  contrac- 
tions have  been  brought  forward  as  one  of  the  means  by  which  the 
inverted  uterus,  can  be  distinguished  from  a  uterine  polypus.  So,  too, 
I  utterly  reject  dependence  upon  the  sensitiveness  of  an  inverted  uterus 
as  a  means  of  diagnosis ;  many  years  ago,  in  a  case  of  doubtful  vaginal 
tumor,  I  held  in  my  hand  that  which  by  other  means  was  proved  to  be 
the  inverted  uterus,  and,  watching  the  face  of  the  patient,  made  two  or 
three  punctures  of  the  tumor  with  an  exploring  needle,  and  not  the 
slightest  shade  of  suffering  passed  over  her  countenance  coincidently 
with  a  puncture.  The  two  signs  that  have  just  been  mentioned,  though 
indorsed  by  high  authorities,  may  possibly  in  some  cases  be  valuable, 
but,  as  a  rule,  I  believe  they  will  prove  doubtful  or  even  deceptive. 

In  rare  instances  inversion  of  the  uterus  has  occurred  some  days 
after  labor.  It  is  most  probable,  however,  that  in  such  cases  there  was 
already  an  unrecognized  partial  inversion,  beginning  at  or  soon  after 
delivery,  which  under  the  influence  of  contractions  was  converted  into 
a  complete  condition. 


1  Kormann. 


INJURIES  OF  THE  MATERNAL  SOFT  PARTS.  571 

PROGNOSIS.  Acute  puerperal  inversion  of  the  uterus  is  a  condition 
of  immediate  and  great  peril.  Even  though  restoration  of  the  organ 
be  promptly  accomplished,  death  may  follow,  as  in  a  case  reported  by 
Breus.1  Crosse's  statistics  show  that  of  109  patients  who  died,  a  fatal 
result  occurred  in  79  within  a  few  years,  in  8  at  the  end  of  a  week, 
and  in  6  after  a  mouth.  Crampton's2  statistics  include  120  cases  of 
puerperal  inversion  of  the  uterus ;  and  of  these  87  recovered,  and  32 
died.  If  the  unhappy  victim  has  escaped  death  from  shock  or  hemor- 
rhage, sloughing  of  the  uterus  in  consequence  of  constriction  by  the 
neck  may  bring  a  fatal  issue  early  in  the  puerperal  period.  Winckel 
mentions  among  causes  of  death  peritonitis,  exhaustion,  septicaemia, 
anaemia,  pyaemia  with  abscesses  of  both  ovaries  (Hofmeier).  Spontane- 
ous restoration  of  an  inverted  uterus,  even  months  or  years  after  the 
accident,  has  occurred  in  very  rare3  instances,  but  the  probability  of 
this  event  is  too  slight  to  sustain  a  rational  hope. 

Treatment. — Immediate  restoration  of  the  organ  to  its  normal  place 
is  indicated,  and  the  sooner  after  the  accident  the  effort  is  made  the 
greater  the  probability  of  success.  Supposing  the  placenta  to  be  still 
attached/  it  is  first  removed,  and  then  the  obstetrician  grasps  the  uterus 
in  his  hand — antiseptics  being  used,  and,  if  the  patient's  condition  does 
not  forbid,  she  is  anaesthetized — presses  the  organ  upward,  being  care- 
ful to  avoid  the  sacral  promontory,  and  at  the  same  time  with  the 
other  hand  counter-pressure  is  made  through  the  abdominal  wall ;  and 
possibly  the  fingers  of  this  hand  may  be  usefully  employed  in  overcom- 
ing the  resistance  of  the  entrance  to  the  uterine  cavity  now  opening  into 
the  abdomen.  The  fingers  of  the  hand  which  holds  the  uterus  may  be 
usefully  employed  in  dilating  the  external  ring-like  cervix,  while  the 
palm  presses  the  uterus  against  the  internal  resisting  portion  of  it.  It 
will  be  observed  that  in  this  manipulation  the  taxis  is  peripheral,  and 
the  effort  is  made  to  restore  first  that  part  of  the  uterus  which  came 
out  last. 

Another  mode  of  restoration  is  by  pressure  directly  made  upon  the  fundus  : 
this  pressure  is  usually  made  by  the  fingers  of  one  hand  brought  together  in  the 
form  of  a  cone :  of  course,  the  finger-nails  are  short ;  the  attempt  is  made  to 
depress  that  portion  of  the  uterus  against  which  the  fingers  push,  and  thus  begin 
the  restoration.  The  taxis  in  this  case  is  central,  and  the  part  of  the  uterus 
restored  first  is  that  which  came  out  first.  The  third  method  is  that  first  sug- 
gested and  successfully  employed  by  Noeggerath,  and  consists  in  pressure  upon 
one  side  of  the  uterus  at  a  point  corresponding  with  the  entrance  of  an  oviduct, 
indenting  or  depressing  the  surface  there,  and  thus  starting  the  restoration ;  this 
method  has  been  called  that  of  lateral  taxis. 

After  the  restoration  of  the  uterus  by  one  or  the  other  of  these  plans, 
the  hand,  of  course  being  in  the  uterus  at  the  completion  of  the  reduc- 

1  Wien.  med.  Woch  ,  1882. 

2  American  Journal  of  Obstetrics,  1885. 

3  Schiitz:  Centl.  f.  Gynak.,  1892,  states  that  ten  cases  of  spontaneous  reinversion  are  known. 

4  Obstetricians  are  not  agreed  as  to  whether  the  placenta  should  be  removed,  provided  no  sepa- 
ration has  begun,  before  restoration  of  the  inverted  organ  is  attempted.    The  argument  in  favor 
of  its  removal  first  is  that  this  can  be  much  more  readily  accomplished  before  than  after  the  re- 
duction, and  that  reduction  will  be  more  readily  effected  without  than  with  the  placenta,  and  that 
a  reinversion  is  liable  to  occur  in  delaying  the  removal  until  after  the  restoration.     The  argument 
against  it  is  that  thereby  hemorrhage  is  at  once  caused ;  undoubtedly,  too,  we  are  less  liable  to 
injure  the  uterine  walls  by  pressure  with  the  cone-formed  fingers  or  with  the  fist,  when  these  walls 
are  in  part  protected  by  the  intervening  placenta. 


572  THE  PATHOLOGY  OF  LABOR. 

tion,  is  used  to  stimulate,  the  external  hand  assisting,  the  uterus  to  con- 
tract. Barnes  says  care  should  be  taken  to  avert  what  has  happened, 
reinversion,  and  for  this  purpose  he  directs  passing  along  the  palm  of 
the  hand  a  uterine  tube  connected  with  an  injecting  syringe  and  throw- 
ing up  a  pint  of  hot  water,  110°  Fahr. 

If  the  physician  is  not  called  to  the  patient  until  several  hours  after 
the  accident,  or  if  previous  efforts  have  been  made  without  success, 
should  he  at  once  attempt  the  reduction?  The  answer  depends  upon 
the  condition  of  the  uterus :  if  it  is  not  inflamed  and  very  sensitive, 
and  if  it  is  relaxed,  gentle  efforts  at  restoration  may  be  made  even 
though  a  day  or  two  have  passed.  Atthill1  takes  the  ground  that  if  an 
effort  at  reduction  has  not  been  made  within  twenty-four  hours  after 
labor,  it  is  better  to  wait  until  after  uterine  involution  has  been  com- 
pleted before  attempting  restoration.  The  reason  for  this  delay  is  that 
the  uterine  tissues  during  involution  are  more  liable  to  be  lacerated  in 
the  manipulation  necessary  for  reduction. 

Nevertheless  Spiegelberg  held  that  if  reposition  did  not  succeed  by 
manual  means,  the  case  should  be  treated  as  if  it  were  a  chronic  inver- 
sion, the  best  course  to  adopt  unquestionably  being  "  to  exert  continuous 
and  steady  pressure  on  the  fuudus  by  means  of  elastic  bags.  These 
will  probably  always  have  the  wished  for  result,  before  the  puerperal 
involution  of  the  uterus  is  complete." 

The  danger  of  infection  is  necessarily  so  great  pursuing  the  plan  ad- 
vised by  Spiegelberg,  we  believe  it  should  be  rejected  ;  it  would  be  safer 
to  follow  the  advice  given  by  Atthill.  In  case  hemorrhage  should  occur, 
which  is  not  probable  because  of  the  constriction  of  the  vessels  conse- 
quent upnn  the  displacement,  it  certainly  can  be  arrested  by  the  appli- 
cation of  an  antiseptic  gauze  tampon,  and  this  may  be  removed  after  a 
few  hours,  and  renewed  as  occasion  may  require. 

It  should  be  remembered,  however,  that  uterine  hemorrhage  in  these 
cases  is  suppressed  by  lactation,  and,  therefore,  nursing  ought  to  be 
strictly  directed. 

1  Diseases  of  Women,  Dublin,  1880. 


CHAPTER    X. 

OBSTETRIC   OPERATIONS. 

INTRODUCTORY.  Obstetric  operations  are  divided  into  those  done 
before,  during,  and  after  labor.  Many  in  the  first  class  have  already 
been  described,  e.  g.,  correcting  posterior  displacements  of  the  gravid 
uterus,  the  application  of  the  tampon,  etc. 

Position  of  the  Patient.  This,  of  course,  will  depend  upon  the  charac- 
ter of  the  operation.  In  the  majority  of  cases  she  will  be  on  her  back, 
lying  across  the  bed,  her  hips  brought  close  to  its  edge.  In  some 
instances,  however,  she  must  be  upon  an  operating-table,  properly  pre- 
pared for  the  occasion. 

In  certain  cases,  as  will  hereafter  be  explained,  lying  upon  one  or 
the  other  side  is  advisable.  So,  too,  as  has  been  previously  explained, 
the  knee-chest  position  may  be  tried  in  restoring  a  retroverted  or  a 
retroflexed  uterus. 

Asepsis,  Antisepsis.  Perfect  cleanliness  of  the  operator's  hands  and 
instruments  and  of  the  external  sexual  organs  and  of  the  vagina  is  of 
first  importance.  Moreover,  let  antiseptic  means  be  also  used.  To 
this  end  the  reader  is  referred  to  the  topics  of  subjective  and  objective 
disinfection  considered  in  connection  with  the  conduct  of  labor.  Here 
I  shall  only  say  that  as  an  antiseptic  for  washing  out  the  vagina  and 
bathing  the  vulva  a  solution  of  lysol  is  sufficient,  if  used  freely ; 
while  most  operators  will  hardly  think  of  performing  a  grave  operation 
without  their  hands  have  been  disinfected  with  a  solution  of  corrosive  sub- 
limate, in  addition  to  the  thorough  washing  which  has  been  described. 

Phenosalyl.  There  lias  recently  been  successfully  employed1  somewhat  in 
France  a  new  antiseptic  called  ph'enosalyl.  The  following  is  the  formula  for  this 
compound : 

Phenic  acid 9      grammes. 

Salicylic  acid 1     gramme. 

Lactic  acid 2     grammes. 

Menthol 0.10  centigramme. 

The  product  is  a  colorless,  syrupy  liquid,  having  an  aromatic  odor,  and  readily 
soluble  in  water.  As  a  microbicide  i£  ranks  next  to  corrosive  sublimate,  and  its 
antiseptic  power  is  more  than  three  times  as  great  as  that  of  carbolic  acid,  double 
that  of  lysol,  and  more  than  double  that  of  creolin.  It  has  been  employed  in  the 
proportion  of  30  grammes  to  1000  of  water  for  washing  the  hands  of  the  obstetri- 
cian, for  bathing  the  vulva,  and  for  vaginal  injection.  In  has  no  injurious  eifect 
upon  the  skin,  as  carbolic  acid  and  corrosive  sublimate  solution  frequently  have. 

ANESTHESIA.  In  the  majority  of  operations  an  anaesthetic  will  not 
be  necessary,  e.  g.,  in  tamponing,  bimanual  version,  etc.,  and  in  some 
it  will  be  forbidden.,  e.  g.,  acute  inversion  of  the  uterus,  or  in  other 
condition  attended  with  profound  shock.  Anaesthesia  will  be  necessary 

1  Revue  M6dico-Chirurgicale  des  Maladies  des  Femmes,  February,  1895. 


574  THE  PA THOLOG  Y  OF  LABOR. 

in  the  graver  operations,  such  as  Csesarean  section,  while  it  may  be 
optional  in  applying  forceps.  Ahlfeld  recommends  ether  as  less  danger- 
ous than  chloroform  ;  it  is  contraindicated  by  bronchitis  or  pneumonia. 

Anaesthesia  will  be  essential  in  overcoming  some  of  the  conditions 
that  may  occur  in  labor,  as,  for  example,  tetanus,  or  spastic  stricture  of 
the  uterus. 

OBJECTS  OF  OPERATING.  Some  operations  are  done  solely  in  the 
interest  of  the  mother,  as  inducing  abortion  because  of  obstinate  vomit- 
ing; others  have  their  only  object  in  saving  the  child,  as  the  Cassarean 
section  in  a  dying  or  upon  a  dead  woman  ;  and  finally,  most  are  done 
in  the  interest  of  both  mother  and  child. 

INDUCTION  OF  ABORTION.  The  arrest  of  pregnancy  prior  to  the 
viability  of  the  foetus  is  much  oftener  done  with  criminal  than  for  thera- 
peutic purpose. 

Historical  Notice.  Artificial  abortion  was  frequent  in  ancient  times,  without 
regard  to  saving  the  mother's  life.  In  the  Republic  of  Plato  its  production  is 
authorized  in  certain  circumstances.1  Aristotle  not  only  did  not  condemn  the 
practice,  but  even  "  desired  that  it  should  be  enforced  by  law  when  population 
had  exceeded  certain  assigned  limits."  Lecky2  remarks  that  the  general  opinion 
among  the  ancients  seems  to  have  been  that  the  foetus  was  but  a  part  of  the 
mother,  and  that  she  had  the  same  right  to  destroy  it  as  to  cauterize  a  tumor 
upon  her  body.  It  seems  to  have  resulted  among  the  Romans  not  simply  from 
licentiousness  and  poverty,  "  but  even  from  so  slight  a  motive  as  vanity,  which 
made  mothers  shrink  from  the  disfigurement  of  childbirth."  The  practice  was 
avowed  and  universal.  Ploss3  refers  to  the  prevalence  of  abortion,  both  in  civi- 
lized and  savage  nations,  this  prevalence  being  especially  great  among  Orientals, 
because  of  the  slight  value  attached  to  the  life  of  the  foetus.  The  maternal 
instinct,  which  acts  as  a  check  to  the  crime,  is  counterbalanced  among  the 
Mohammedans  by  the  severe  punishment  inflicted  upon  a  woman  who  has  an 
illegitimate  child. 

Christianity  was  the  most  influential  factor  in  revolutionizing  Roman  senti- 
ment, and  to-day  is  the  most  powerful  protection  of  the  unborn  babe.  Lecky, 
after  stating  that  the  average  Roman  in  the  later  days  of  Paganism  thought  arti- 
ficial abortion  only  a  venial  crime,  scarcely  deserving  censure,  says,  "Ihe  lan- 
guage of  the  Christians  from  the  very  beginning  was  very  different.  With 
unwavering  consistency  and  with  the  strongest  emphasis  they  denounced  the 
practice,  not  simply  as  inhuman,  but  as  definitely  murder.  In  the  penitential 
discipline  of  the  Church  abortion  was  placed  in  the  same  category  as  infanticide, 
and  the  stern  sentences  to  which  the  guilty  person  was  subject  imprinted  on  the 
minds  of  Christians,  more  deeply  than  mere  exhortations,  a  sense  of  the  enor- 
mity of  the  crime."  Fortunate  is  that  people  or  that  community  in  which  this 
sentiment  prevails,  reinforcing  civil  law,  and  strengthening  the  teaching  of  med- 
ical science  in  regard  to  artificial  abortion  when  resorted  to  from  any  other 
motive  than  the  salvation  of  the  mother's  life. 

Klein wachter  states  that  it  appears  from  the  writings  of  Aspasia,  fragments  of 
which  have  been  received  through  ^Etius,  who  lived  in  the  fifth  century,  that 
the  ancient  Greeks  resorted  to  abortion  in  narrow  pelves.  With  the  extension 
of  Christianity,  however,  even  this  form  of  abortion  disappeared,  and  was  only 
preserved  among  the  Arabs,  as  we  learn  from  Rhazes  and  Avicenna.  Further 
reference  to  this  operation  is  not  made.  It  reappeared  in  the  middle  of  the 
seventeenth  century,  when  it  was  recommended  by  the  famous  German  midwife, 
Justin  Siegmundin,  for  placenta  prsevia ;  but  it  seems  most  probable,  notwith- 
standing Kleinwachter's  statement,  that  she  adopted  this  practice  from  French 
obstetricians.  It  was  employed  first  in  England  by  W.  Cooper  in  1717,  in  order 
to  avoid  the  great  mortality  of  the  Csesarean  operation.  It  was  recommended 
for  the  same  reason  by  Scheel  in  Copenhagen  in  1799.  It  was  warmly  advocated 

1  Jowett's  Translation,  vol.  iii.  p.  343.  2  History  of  Morals  In  Europe.  8  Op.  cit. 


OBSTETRIC  OPERATIONS.  575 

by  Mende  in  Germany,  1802,  and  by  Fodere  in  France,  1835,  and  subsequently 
by  Dubois  and  Cazeaux. 

INDICATIONS  FOR  ARTIFICIAL  ABORTION.  These  indications  may 
depend  upon  some  general  disease  of  the  mother,  or  upon  some  local 
disease  or  deformity,  or  upon  disease  of  the  ovum. 

1.  Whenever  the  mother  is  suffering  from  disease  caused  by  preg- 
nancy or  originating  before  it,  or  accidentally  occurring  during  it,  which 
imperils  her  life,  and  there  is  a  reasonable  probability  that  she  will 
recover  after  abortion,  it  is  indicated.  Among  these  diseases  may  be 
mentioned  the  uncontrollable  vomiting  of  pregnancy,  and,  in  some  cases, 
chorea  and  nephritis. 

The  question  of  producing  abortion  in  case  of  serious  retinal  disease  has  been 
in  recent  years  presented  more  especially  by  American  oculists.  The  view  held 
by  them  is  offered  in  the  extract  from  Dr.  Noyes's  volume,  which  will  be  given 
in  a  moment ;  it  will  be  observed  that  the  author  uses  the  words  "  premature 
labor,"  though  abortion  is  plainly  meant.  If  hopeless  blindness  is  to  be  the 
consequence  of  the  continued  pregnancy,  though  the  mother  may  escape  eclamp- 
sia and  the  child's  life  be  saved,  is  abortion  justifiable  ?  This  is  one  of  the  most 
difficult  questions  in  obstetric  casuistry,  and  its  decision  must  be  left  to  the  prac- 
tititioner,  and  especially  to  the  woman  and  her  friends.  Knowing  instances  af 
hopeless,  helpless  blindness  thus  originating,  my  opinion  is  that  abortion  is  justi- 
fiable to  prevent  this  great  evil,  if  the  woman  and  her  friends  insist  upon  it. 

Noyes  says  :l  "  Loring  published  a  case  in  1882,  in  which,  at  his  suggestion, 
premature  labor  was  resorted  to  to  save  sight  in  a  woman  who,  at  three  succes- 
sive pregnancies,  was  the  subject  of  atrophy  of  the  optic  nerves,  or  rather  of  low 
neuritis  optica.  This  was  successfully  done  during  the  third  month  and  achieved 
the  desired  purpose.  No  albumin  was  found  in  the  urine,  yet  the  lesion  was 
attributed  to  the  kidneys.  Howe,  Pooley,  and  Moore  have  recorded  cases 
wherein  the  retinal  disease  was  clearly  pronounced,  and  by  removal  of  the  foetus 
sight  was  restored.  .  .  .  The  grave  significance  of  loss  of  sight  as  denoting 
advanced  degeneration  of  the  kidneys  lends  added  importance  to  the  situation, 
and  must  be  considered  as  arguing  in  favor  of  interference.  The  uramic  state 
of  the  blood  is  dangerous  to  the  life  of  the  foetus ;  when  it  has  already  caused 
lesions  in  the  optic  nerve  and  retina  of  the  mother,  and  with  the  prospect  of 
convulsions  and  peril  to  the  mother's  life,  resort  to  artificial  labor  may  be  abun- 
dantly justified.  This  point  in  the  management  of  labor  must  in  the  future  be 
regarded  with  more  attention  than  it  has  received ;  and  because  there  may  be 
lesions  of  the  nerve  or  retina  without  impaired  sight,  inspection  with  the  oph- 
thalmoscope is  strongly  recommended  for  the  same  prudential  reasons  which  call 
for  the  examination  of  the  urine,  even  though  there  are  no  urgent  symptoms. 
Vision  may  also  be  impaired  with  little  or  no  visible  lesion." 

I  asked  my  friend  Dr.  G.  M.  Gould  to  give  me  his  opinion  upon  interruption  of 
pregnancy  on  account  of  albuminuric  retinitis,  and  the  following  is  his  reply : 

DEAR  DR.  PARVIN  :  The  existence  of  albuminuric  retinitis  in  pregnancy  is 
such  a  grave  symptom,  whether  as  regards  the  mother  or  the  child,  that  it  would 
seem  as  if  one  could  hardly  err  in  immediately  ending  the  pregnancy.  In  this 
connection  it  might  be  urged  that  the'ophthalmoscopic  examination  in  all  cases, 
even  of  suspected  nephritis,  should  not  be  omitted,  because  it  not  seldom  hap- 
pens that  the  eyeground  will  show  signs  of  the  kidney  disease  before  other 
symptoms  are  noticed.  At  all  events,  whenever  the  retinal  lesions  are  evident  it  is 
high  time  for  alarm,  because  eclampsia  may  supervene  and  the  life  of  the  foetus  be 
endangered  from  this  cause,  or  the  renal  disease  may  so  damage  the  kidneys  that 
nephritis  will  persist  after  the  pregnancy  has  been  terminated.  From  the  stand- 
point of  the  ophthalmologist  alone,  and  looking  only  to  the  threatened  loss  of 
vision,  as  if  that  were  the  single  function  to  be  considered,  it  might  be  contended 
that  recovery  of  useful  vision  may  undoubtedly  follow  very  severe  inflammations 
of  the  retina  and  optic  nerve.  In  reality  this  is  a  strong  argument  for  inducing 

1  Text-book  on  Diseases  of  the  Eye,  1890. 


576  THE  PATHOLOGY  OF  LABOR. 

premature  labor  in  the  extremest  cases  of  retinal  injury  from  the  nephritis  of 
pregnancy.  If  albuminuria  has  existed  without  producing  any  noteworthy 
symptoms,  one  may  procrastinate  according  to  his  judgment,  but  it  would  ap- 
pear clear  to  me  that  with  the  first  pronounced  symptoms  of  retinal  disease, 
whether  objective  or  subjective,  there  remains  but  one  duty  for  the  obstetrician 
to  perform. 

2.  In  case  of  such  obstruction  of  the  birth-canal,  either  from  pelvic 
deformity  or  from  neoplasms,  that  a  living  child  cannot  be  born  through 
the  natural  passage  even  if  premature  labor  be  induced,  and  especially 
if  the  obstruction  be  so  great  that  delivery  is  impossible  after  embry- 
otomy,  the  indication  for  abortion  is  by  most  regarded  as  clear.     This 
much  all  must  admit :  that  a  plain  statement  of  the  facts  should  be 
made  to  the  pregnant  woman,  and  then  let  her  take  her  choice  between 
abortion  and  the  CaBsarean  section  at  the  end  of  pregnancy.     There  is 
no  doubt  as  to  what  that  decision  will  be  in  nine  cases  out  of  ten ;  and 
certainly,  even  if  embryotomy  be  possible  at  the  end  of  gestation,  an 
early  abortion  will  be  less  dangerous. 

3.  Certain  uterine  displacements,  such  as  retroversion  or  retroflexion, 
with  incarceration,  render  abortion  necessary. 

4.  Diseases  of  the  ovum  may  require  it.     Detachment  of  the  ovum 
may  have  occurred,  and  hemorrhage  demands  that  the  pregnancy  be 
ended,  or  the  same  indication  be  presented  by  cystic  degeneration  of  the 
chorion. 

Among  rarer  causes  for  artificial  abortion  are  malignant  disease  of 
the  uterus,  emptying  its  cavity  being  done  preparatory  to  extirpation ; 
death  of  the  ovum  with  delayed  expulsion — that  is,  missed  abortion ; 
hypertrophy  of  the  thyroid,  hypertrophy  of  the  mam  rase  (Porro),  and 
sometimes  cardiac  or  acute  pulmonary  disease. 

Lomer1  presents  cases  in  which  the  following  are  given  as  causes  for  artificial 
abortion :  1,  retention  of  the  dead  fo3tus ;  2,  severe  chronic  cystitis  with  obsti- 
nate vomiting ;  3,  obstinate  vomiting ;  4,  obstinate  vomiting,  the  vomiting  con- 
tinued in  a  severe  form  for  a  time  after  emptying  the  uterus ;  5,  eclampsia ;  6, 
grave  acute  nephritis ;  7,  chronic  nephritis  and  threatened  eclampsia ;  8,  hydror- 
rhoea  and  hemorrhage ;  9,  anaemia  from  placenta  prsevia ;  10,  purulent  decidual 
endometritis  and  rigors;  11,  melancholia  with  sleeplessness,  emaciation,  and 
nervous  cough;  12,  intestinal  and  pulmonary  tuberculosis ;  13,  early  manifested 
and  large  varices ;  14,  multiple  spinal  sclerosis. 

In  regard  to  the  indication  12,  William  Duncan,2  1889,  induced  abortion  on 
account  of  phthisis ;  Valenta,  1877,  and  Seidler,  St.  Petersburg,3  advocated  it 
early  in  1889.  It  seems  to  be  admitted  that  it  is  advisable  in  laryngeal  tubercu- 
losis. But  in  general  the  operation  does  not  save,  only  prolongs  the  mother's 
life.  Lomer  brings  a  strong  argument  in  favor  of  interrupting  the  pregnancy 
from  the  statistics  of  Professor  Maragliano,  showing  that  in  forty-two  pregnant 
women  having  circumscribed  tuberculosis  of  the  pulmonary  apices,  94  per  cent, 
were  dead  within  a  year  after  labor,  while  in  one  hundred  and  eighty-eight 
analogous  cases,  the  women  not  becoming  pregnant,  the  mortality  in  twenty-one 
months  was  only  34  per  cent. 

These  statistics  are  of  very  great  importance,  as  showing  the  great  evil  preg- 
nancy is  to  a  tuberculous  woman.  But  they  do  not  prove  that  artificial  abortion 
prolongs  life  in  such  cases. 

1  Ueber  kUntslichen  Abortus  bei  Allgemeinerkrankung  der  Mutter,  1894. 

2  Transactions  of  the  London  Obstetrical  Society,  1890. 
»  Centralb.  f.  Gynakol.,  1894. 


OBSTETRIC  OPERATIONS.  577 

PROGNOSIS  AND  MEANS. — The  prognosis  will  depend  upon  the  con- 
dition of  the  patient  and  the  cause  rendering  the  operation  necessary  ;  it 
is  generally  favorable. 

After  careful  disinfection  of  the  parts,  the  next  step  is  gradual  dilata- 
tion of  the  cervical  canal  with  aseptic  lamiuaria  or  tupelo  tents,  the 
latter  the  better,  or  immediate  dilatation,  the  patient  being  anaesthetized, 
by  means  either  of  solid  dilators  or  those  having  blades,  and  then  pos- 
sibly the  smallest  of  Barnes's  dilators  may  be  used.  Some  have  intro- 
duced iodoform  gauze  into  the  cervical  canal,  removing  the  packing 
after  twelve  or  twenty-four  hours,  and  repeating  it  as  necessary  ;  the 
introduction  of  a  bougie,  or  partial  detachment  of  the  membranes  may 
excite  uterine  action — puncture  of  the  membranes  is  not  advisable,  at 
least  in  the  earlier  months. 

After  the  abortion  has  begun  the  treatment  will  be  similar  to  that 
given  on  pages  471-6. 

INDUCTION  OF  PREMATURE  LABOR.  Labor  is  induced  prematurely 
if  the  continuance  of  the  pregnancy  until  term  would  cause  serious 
danger  to  the  mother  or  to  the  child ;  it  seeks  to  save  the  life  of  each, 
not  sacrificing  that  of  one  for  the  sake  of  the  other. 

The  operation  was  introduced  into  obstetric  practice  more  than  a  century  ago 
by  British  obstetricians,  the  most  famous  of  them  being  Thomas  Denman :  it 
was  sooner  and  more  readily  accepted  in  Germany  than  in  France,  and  the  former 
country  has  furnished  the  most  important  contributions  to  the  study  of  the  indi- 
cations and  methods  for  inducing  labor. 

INDICATIONS.  Many  of  these  have  already  been  stated  in  con- 
sidering artificial  abortion.  The  most  frequent  of  all  is  a  pelvic 
deformity  so  great  that  only  a  mutilated  child  can  be  extracted  at 
term,  and  yet  permitting  a  living  child  to  be  born  if  premature  labor 
occurs. 

Stehberger  proposed,  and  the  proposition  was  indorsed  by  Spiegelberg  and 
others,  that  if  a  pregnant  woman  is  suffering  with  a  disease  which  will  prove 
fatal  before  the  normal  end  of  pregnancy,  premature  labor  may  be  induced  in 
order  that  the  life  of  the  child  may  be  secured  rather  than  expose  it  to  the 
doubtful  chance  of  being  extracted  alive  by  Caesarean  operation  performed  after 
the  mother's  death.  But  can  the  date  of  death  be  foretold  with  anything  like 
certainty  ?  And  can  the  obstetrician  ever  be  quite  sure  that  the  induction  of 
premature  labor  will  not  shorten  the  mother's  days?  Of  course  if  this  operation 
is  ever  done,  with  such  indication,  the  mother's  wish,  not  merely  her  consent 
obtained,  must  be  for  it.  , 

PELVIC  CONTRACTION.  In  the  justo-minor  pelvis  with  a  true  con- 
jugate of  9  centimeters  (3.5  inches),  the  induction  of  premature  labor  is 
indicated,  according  to  Litzmanu.  So,  too,  it  is  preferable  to  the 
Csesarean  operation,  Dohrn  holds,  in  the  moderately  contracted  pelvis  if 
the  true  conjugate  is  7  to  8  centimetres.  Wmckel  teaches  that  in  con- 
tracted pelves  of  8  centimetres  and  above,  we  are  only  justifiable  in 
inducing  labor  if  previous  children  have  died  during  or  as  a  result  of 
the  labor,  because  they  were  especially  well  developed. 

The  time  for  inducing  labor  will  be  decided  by  the  degree  of  deformity. 
If  the  conjugata  vera  is  7  centimetres,  labor  is  induced  at  the  comple- 

37 


578  THE  PATHOLOGY  OF  LABOR. 

tion  of  seven  mouths ;  if  7  J,  at  the  middle  of  the  eighth  month ;  and 
if  8,  at  its  completion  ;  if  8J,  at  eight  and  a  half  months.1 

DISEASE  OF  THE  MOTHER.  This  may  be  one  existing  prior  to  preg- 
nancy, and  aggravated  by  it,  or  it  may  be  directly  connected  with  or 
consequent  upon  the  gestation,  or  it  may  be  an  accidental  malady. 
Peter  held  that  if  gravido-cardiac  accidents  are  attended  with  great 
and  immediate  peril  in  the  pregnant  woman,  the  induction  of  premature 
labor  is  indicated. 

Dujardin-Beaumetz2  states  that,  "The  most  serious  complications  and  the 
greatest  danger  of  death  for  the  mother  appear  at  seven  and  a  half  or  eight 
months.  In  presence  of  this  fact,  is  the  physician  warranted  in  inducing  prema- 
ture labor  ?  Durosier  replies  in  the  affirmative,  and  a  great  many  obstetricians 
say  the  same." 

Schroder  .referred  to  conditions  which  cause  danger  of  suffocation, 
thus  especially  diseases  of  the  organs  of  respiration  and  circulation,  and 
mechanical  hindrance  to  respiration  in  consequence  of  distention  of  the 
abdomen,  as  giving  occasion  for  premature  labor. 

Renal  disease  may  be  an  indication.  If  this  causes  great  oedema, 
scanty  urinary  secretion,  and  there  are  symptoms  threatening  eclampsia, 
and  when  appropriate  treatment,  especially  the  hot-water  bath,  does  not 
avert  the  dangerous  indications,  labor  may  be  induced :  but  it  ought  not 
be  resorted  to  simply  on  account  of  the  "kidney  of  pregnancy."  The 
obstinate  vomiting  of  pregnancy  is  recognized  as  justifying  the  operation 
in  some  cases,  and  a  similar  statement  may  be  made  as  to  chorea.3 

Premature  labor  has  been  induced,  according  to  the  statement  of  Pippingskold, 
in  eclampsia,  with  meningitis,  croupous  laryngititis,  mammary  carcinoma,  and 
hectic  fever  connected  with  pelvic  abscess.  It  was  advised  by  Ferrario  in  epi- 
lepsy, apoplexy,  eclampsia,  dropsy,  pneumonia,  and  severe  hemorrhage. 

HABITUAL  DEATH  OF  CHILD. — Denman,4  while  recognizing  pelvic 
deformity  as  the  chief  cause  for  the  induction  of  premature  labor,  also 
advised  it  in  case  of  the  death  of  the  child  near  the  end  of  pregnancy, 
to  be  done  in  subsequent  pregnancies,  and  related  two  instances  in 
which  he  successfully  employed  this  practice.  This  indication  has 
been  recognized  by  several  eminent  obstetricians  since,  among  whom 
may  be  mentioned  Sir  James  Simpson ;  but  in  recent  years  less  atten- 
tion has  been  given  to  it,  some  even  deny  "  habitual  death  of  foetus," 
and  Spiegelberg,  excluding  all  cases  in  which  the  cause  of  foetal  death 
was  organic  disease,  especially  syphilis,  from  the  operation,  stated  that 
a  successful  case  must  always  be  regarded  as  an  exception.  Winckel 
takes  a  broader  view,  and  would  not  deny  the  operation  even  though 
the  premature  death  is  caused  by  hereditary  syphilis. 

The  following  is  an  extract  from  a  paper  read  before  one  of  our  State 
medical  societies  a  few  years  since  : 


1  In  reference  to  these  rules,  variations  from  them  will  be  presented  in  considering  sympbysi- 
otomy. 

2  Op.  cit.,  Diseases  of  the  Heart,  translated  from  the  French  by  Dr.  E.  P.  Hurd. 

3  Berlin  klin.  Wochen..  1870. 

*  London  Lancet,  January  4, 1845  :  An  Introduction  to  the  Practice  of  Midwifery. 


OBSTETRIC  OPERATIONS.  579 

"  I  have  induced  labor  twice,  solely  for  my  own  and  for  the  convenience  of  my 
patients."  It  is  to  be  regretted  that  this  statement  met  with  no  rebuke  at  the 
time  it  was  made.  When  we  consider  that  there  is  no  certain  method  of  induc- 
ing premature  labor  which  secures  immunity  from  infection,  but  increases, 
though  in  slight  degree,  the  liability  to  such  infection,  the  obstetrician  is  never 
justified  in  exposing  a  woman  to  this  risk  for  his  own  or  for  her  convenience. 

Barlow,  in  his  Essays  on  Surgery  and  Midwifery,  published  in  1822,  has  as  the 
motto  of  the  essay  upon  inducing  premature  labor  this  line  from  Horace's  Art  of 
Poetry  : 

"Nee  Deus  intersit,  nisi  dignus  vindice  nodus." 

This  maxim  might  well  be  pondered  by  any  one  who  should  for  a  moment 
think  of  imitating  the  bad  practice  referred  to. 

PROGNOSIS. — According  to  Wyder's  statistics,  5  per  cent,  of  the 
mothers,  and  50  per  cent  of  the  children,  die  ;  Winckel  states  that  of 
the  children  born  at  seven  and  a  half  to  eight  months,  only  33  per  cent, 
are  actually  kept  alive.1 

MEANS  OF  INDUCING  LABOR. — The  question  was  a  very  simple 
one  for  the  obstetricians  of  Denman's  day ;  they  recognized  but  one 
method,  as  indicated  by  his  statement  "No  person  qualified  to  decide 
on  the  propriety  of  this  operation  can  be  ignorant  of  the  manner  of  per- 
forming it,  whether  it  be  done  with  a  quill  sharpened  at  the  point,  or 
any  more  formal  instrument."  He  frankly  stated  that  while  in  some 
instances  labor  happened  in  twelve  hours  after  puncturing  the  mem- 
branes, in  others  it  did  not  under  twelve  or  fifteen  days. 

Winckel  gives  nineteen  different  methods.  Krause's  method  is  that 
generally  preferred.  It  is  the  introduction  of  a  flexible  bougie  between 
the  ovum  and  the  uterine  wall ;  before  this  introduction  the  vagina 
must  be  well  washed  out  with  an  antiseptic  solution,  the  hand  of  the 
operator  must  be  first  made  aseptic  as  well  as  the  instrument ;  if  labor 
does  not  come  on  within  twenty-four  hours,  a  second  bougie  is  intro- 
duced in  a  different  direction,  the  first  having  been  withdrawn  :  great 
gentleness  must  be  observed  in  the  introduction  of  the  bougie  lest  the 
membranes  be  torn  or  the  placenta  be  partially  detached — it  must  be 
made  to  "feel"  its  way  in.  In  some  cases  the  uterus  may  be  so  ante- 
flexed,  or  the  cervical  canal  be  so  contracted,  that  the  bougie  cannot  be 
introduced ;  then  a  tupelo  tent  may  be  first  used  in  narrowed  cervix, 
and  also  in  flexion — in  the  latter  case  it  can  only  be  passed  at  first  as 
far  as  the  bend,  and  great  care  must  be  taken  not  to  do  any  violence  by 
trying  to  push  it  further.  In  all  these  manipulations  an  antiseptic  in- 
jection into  the  vagina  must  bte  made,  not  only  before  the  introduc- 
tion of  bougie  or  tent,  but  also  after  its  removal  and  inserting  a  new 
one. 

In  case  premature  labor  is  induced  because  of  placenta  praevia.  the  Krause 
method  is  to  be  rejected,  for  the  bougie  in  its  introduction  immediately  causes 
hemorrhage.  Therefore  dilatation  with  tupelo  tent  at  first,  then  with  Barnes's 
dilators,  is  to  be  preferred,  or  even  the  doubtful  method  of  tamponing  the 
vagina. 

Chenevi&re2  has  successfully  employed  the  following  method :  Small  iodoform 
gauze  tampons  are  by  means  of  a  thick  sound  pressed  into  the  cervical  canal,  and 

1  The  results  obtained  by  the  employment  of  the  couveuse  and  of  gavage  show  a  much  lower 
foetal  mortality  than  above  stated. 

2  Kevue  Medicale  de  la  Suisse  Romande,  1889. 


580 


THE  PATHOLOGY  OF  LABOR. 


somewhat  above  the  internal  os,  and  the  canal  is  also  filled,  the  whole  being 
retained  by  a  large  vaginal  tampon. 

•For  the  purpose  of  exciting  uterine  contraction,  Kehrer  has  employed  tampons 
of  cotton  dipped  in  glycerin,  and  then  pressed  in  the  cervical  canal. 

In  the  Krause  method,  a  flexible  catheter  is  not  to  be  used,  but  always  a  bou- 
gie, for  infection  is  more  liable  to  occur  with  the  former.  The  preference  given 
by  some  practitioners  to  the  Kiwisch  method  is  that  by  it  there  is  less  danger  of 
infection. 

Fritsch  advises  introducing  two  or  three  bougies  at  one  time. 

One  danger  from  the  bougie  is  penetrating  the  amnial  sac,  and  another  is  par- 
tially detaching  the  placenta ;  if  the  latter  accident  should  occur,  and  the  bleed- 
ing be  considerable,  a  tampon  of  iodoform  gauze  will  be  employed. 

The  injection  of  water  in  the  uterus  for  bringing  on  labor  was  recommended 
by  Avicenna.  Schweighauser,  in  1825,  advised  injection  of  warm  water,  and 
Schakenberg,  in  1833,  employed  cold  water  for  this  purpose;  Cohen,  of  Ham- 
burg, in  1846,  used  tar-water.  The  statistics  of  Breisky,  united  with  those  of 

FIG.  223. 


BARNES'S  HYDROSTATIC  DILATORS  AND  SYRINGE. 

Sabarth,  show  that  of  62  cases  in  which  Cohen's  method  was  employed,  only  30 
of  the  children  were  born  living.     All  these  methods  have  been  abandoned. 

Pelzer,  in  1892,  employed  intra-uterine  injections  of  glycerin.  Several  obstet- 
ricians have  followed  Pelzer's  plan,  and  usually  prompt  uterine  action  has  re- 
sulted from  injecting  glycerine  between  the  ovum  and  the  uterine  wall.  But 
the  method  has  been  condemned  by  Pfannenstiel  in  consequence  of  some  deaths 
following  it. 

Other  methods  are  by  means  of  Tarnier's  dilator,  Barnes's  rubber 
bags,  the  balloon  of  Champetier,  of  Riber — an  instrument  highly  recom- 


OBSTETRIC  OPERATIONS.  581 

mended  by  many  in  ante-partum  hemorrhage — tamponing  the  vagina, 
hot-water  douche  (Kiwisch's  method),  and  electricity.  The  rubber  bags 
of  Barnes  may  be  usefully  employed  to  accelerate  labor,  but  not  even 
the  smallest  to  begin  it. 

One  of  the  evil  consequences  of  using  the  rubber  bags  of  Barnes,  or  the  bag 
of  Champetier,  is  that  the  presenting  part  of  the  child  may  be  pushed  away 
and  an  unfavorable  presentation  result ;  thus,  in  some  instances,  the  head  has 
been  replaced  by  the  shoulder. 

Grinda,  as  the  result1  of  a  study  of  the  different  means  of  inducing  labor, 
recommends  beginning  with  the  balloon  of  Tarnier,  and  using  his  dilator  as  an 
auxiliary  means. 

VERSION,  OR  TURNING. — Version  is  an  obstetric  operation  by  which 
one  end  of  the  foetal  ovoid  is  substituted  for  the  other,  or  either  for 
presentation  of  a  shoulder.  If  in  this  operation  the  head  is  made  to 
take  the  place  of  the  shoulder  or  pelvis,  the  version  is  called  cephalic  ; 
but  if  the  pelvis  takes  the  place  of  either  of  the  others,  the  version  is 
pelvic ;  and  when  at  the  same  time,  this  being  more  frequently  the  case, 
the  operator  brings  down  one  or  both  feet,  the  version  is  podalic ;  thus 
it  is  evident  that  podalic  is  really  a  variety  of  pelvic  version. 

CEPHALIC  VERSION. — This  variety  of  turning,  as  the  oldest,  will 
be  first  described,  although  it  has  now  passed  into  almost  complete 
disuse.  Indeed,  so  commonly  is  podalic  version  employed  that  to  speak 
of  version,  or  turning,  is  generally  understood  as  bringing  down  one  or 
both  feet.  There  are  two  general  methods  by  which  it  is  performed, 
each  being  bimanual,  but  in  one  of  them  one  hand  is  external  and  the 
other  internal,  while  in  the  other  both  hands  are  external. 

A.  Version  by  internal  and  external  manipulation.  The  great  majority 
of  cephalic  versions  are  performed  in  consequence  of  presentation  of 
the  shoulder,  and  generally  when  the  labor  has  been  so  long  in  progress 
that  rectification  of  the  presentation  is  impossible  by  external  manipu- 
lation, and  therefore  the  method  of  performing  cephalic  version  by  one 
hand  internal  and  the  other  external  must  be  that  which  is  most  fre- 
quently employed. 

There  are  several  ways  of  turning  by  the  head,  and  I  shall  first 
describe  that  of  the  late  Dr.  M.  B.  Wright,  of  Cincinnati,  a  method 
which  has  received  scant  acknowledgment  even  by  American  obstetri- 
cians, and  yet  it  is,  as  those  who  have  tried  it  will  testify,  one  of  the 
safest,  simplest,  and  most  certain. 

The  following  is  Dr.  Wright's2  description  of  this  method  as  given  in  1854: 
"Suppose  the  patient  to  have  been  placed  upon  her  back,  across  the  bed,  and 
with  her  hips  near  the  edge— the  presentation  to  be  the  right  shoulder,  with  the 
head  in  the  left  iliac  fossa — the  right  hand  to  have  been  introduced  into  the 
vagina,  and  the  arm,  if  prolapsed,  having  been  placed  as  near  as  may  be  in  its 
original  position  across  the  breast.  We  now  apply  our  fingers  upon  the  top  of 
the  shoulder,  and  our  thumb  in  the  opposite  axilla,  or  on  such  part  as  will  give 
us  command  of  the  chest,  and  enable  up  to  apply  a  degree  of  lateral  force.  Our 

1  Technique  de  1' Accouchement  premature  artificiel.    Paris,  1891. 

2  Difficult  Labors  and  their  Treatment.    By  M.  B.  Wright,  M.D.,  of  Cincinnati.    For  which  a 
gold  medal  was  awarded  by  the  Ohio  State  Medical  Society,  Cincinnati,  1854. 


582 


THE  PATHOLOGY  OF  LABOR. 


left  hand  is  also  applied  to  the  abdomen  of  the  patient,  over  the  breech  of  the 
foetus.  Lateral  pressure  is  made  upon  the  shoulder  in  such  a  way  as  to  give  the 
body  of  the  foetus  a  curvilinear  movement.  At  the  same  time  the  left  hand, 
applied  as  above,  makes  pressure  so  as  to  dislodge  the  breech,  as  it  were,  and 
move  it  toward  the  centre  of  the  uterine  cavity.  The  body  is  thus  made  to 
assume  its  original  bent  position,  the  points  of  contact  with  the  uterus  are 
loosened,  and  perhaps  diminished,  and  the  force  of  adhesion  is  in  a  good  degree 
overcome.  Without  any  direct  action  upon  the  head  it  gradually  approaches 
the  superior  strait,  falls  into  the  opening,  and  will,  in  all  probability,  adjust 
itself  as  a  favorable  vertex  presentation.  If  not,  the  head  may  be  acted  upon 
as  in  deviated  positions  of  the  vertex,  or  it  may  be  grasped,  brought  into  the 
strait,  and  placed  in  correspondence  with  one  of  the  oblique  diameters."  One 
point  upon  which  Wright  insisted  as  peculiar  to  his  method  was  that  he  did  not 
attempt  to  raise  the  shoulder,  but  regarded  this  manipulation,  advised  by  some 
obstetricians,  as  really  hindering  instead  of  promoting  cephalic  version. 

He  directed  that  the  entire  process  be  done  in  the  intervals  between  uterine 
contractions,  and  that  when  a  vertex  presentation  was  secured  the  practitioner 
should  be  governed  as  to  time  and  manner  of  delivery  by  the  general  rules 
applicable  to  such  presentation. 

FIG.  224. 


CEPHALIC  VERSION.    WEIGHT'S  METHOD. 

Dr.  Wright  first  employed  his  method  successfully  in  three  cases  in  the  year 
1850.  I  believe  his  last  published  contribution  upon  the  subject  was  in  1876.1 
In  the  twenty-six  years  intervening  between  the  first  application  of  his  plan  and 
this  time  he  had  frequent  opportunities  of  verifying  its  value,  and  often  suc- 
ceeded in  cases  in  which  the  shoulder  was  so  impacted  that  others  had  vainly 
attempted  podalic  version.  He  usually  operated  with  the  patient  in  the  posi- 
tion described,  but  in  some  difficult  cases  had  her  take  the  knee-chest  position. 

Three  other  methods  of  performing  cephalic  version  by  one  hand  internally, 
and  the  other  externally,  will  be  given,  two  of  them  antedating  by  many  years 
that  of  Wright,  while  the  third  was  not  published  until  some  years  after  it. 

1  American  Practitioner,  January,  1876. 


OBSTETRIC  OPERATIONS.  583 

1.  Busch  ruptured  the  membranes,  and  immediately  after  passed  his  hand  into 
the  uterus  over  the  occiput  and  to  the  nucha  so  as  to  exercise  a  gentle  traction 
during  the  escape  of  the  waters,  and  to  fix  the  head  in  the  pelvic  inlet  until 
uterine  contractions  occurred.  Coincident  with  this  internal  manipulation  the 
other  hand  was  used  to  act  upon  the  breech  through  the  abdominal  wall.  2. 
D'Outrepont  with  one  hand  introduced  into  the  uterus  lifted  up  the  trunk  of  the 
foetus,  acting  upon  the  presenting  shoulder,  and  with  the  other  through  the 
abdominal  wall  pressed  the  head  out  of  the  iliac  fossa,  in  which  it  was  resting, 
and  into  the  pelvic  inlet.  3.  Braxton  Hicks1  thus  describes  his  method  of 
performing  cephalic  version  :2  "  Introduce  the  left  hand  into  the  vagina  as  in 
podalic  version,  place  the  right  hand  on  the  outside  of  the  abdomen,  in  order 
to  make  out  the  position  of  the  foetus,  and  the  direction  of  the  head  and  feet. 
Should  the  shoulder,  for  instance,  present,  then  push  it  with  one  or  two  fingers 
on  the  top  in  the  direction  of  the  feet.  At  the  same  time  pressure  by  the  outer 
hand  should  be  exerted  on  the  cephalic  end  of  the  child.  This  will  bring  down 
the  head  close  to  the  os ;  then  let  the  head  be  received  upon  the  tips  of  the 
inside  fingers.  The  head  will  play  like  a  ball  between  the  two  hands,  it  will  be 
under  their  command,  and  can  be  placed  in  almost  any  part  at  will.  Let  the 
head  then  be  placed  over  the  os,  taking  care  to  rectify  any  tendency  to  face 
presentation.  It  is  as  well,  if  the  breech  will  not  rise  to  the  fundus  readily  after 
the  hand  is  fairly  in  the  os,  to  withdraw  the  hand  from  the  vagina,  and  with  it 
press  up  the  breech  from  the  exterior.  The  hand  which  is  retaining  gently 
the  head  from  the  outside  should  continue  there  for  some  little  time,  till  the 
pains  have  insured  the  retention  of  the  child  in  its  new  position  by  the  adapta- 
tion of  the  uterine  walls  to  its  form." 

B.  Version  by  external  manipulation,  or  external  bimanuaP  version. 
Hergott  states  that  the  merit  of  having  created  this  method  belongs 
entirely  to  Wigaud.  Wigand  held  that  version  by  external  manoeu- 
vres was  indicated  whenever  at  the  beginning  of  labor  the  presentation 
of  the  foetus  was  abnormal ;  its  purpose  was  to  make  a  regular  presenta- 
tion ;  that  is,  of  one  or  the  other  end  of  the  foetal  ovoid.  When  Fro- 
riep  advised  the  application  of  the  method  in  the  latter  part  of  pregnancy 
before  labor  had  begun,  Wigand  replied  that  he  had  several  times  done 
it  successfully. 

The  time  of  operating  should  be  at  the  beginning  of  labor  or  in  the 
latter  part  of  pregnancy,  and  the  preparations  are  the  same  as  those 
required  for  abdominal  palpation  in  the  diagnosis  of  pregnancy.  A 
careful  diagnosis  of  the  presentation  and  its  variety  is  made  by  palpa- 
tion and  by  auscultation,  and,  also,  if  labor  has  begun,  by  vaginal  touch. 
Upon  turning  to  Fig.  130  it  will  be  observed  that  the  right  shoulder  is 
presenting,  or  would  if  labor  had  begun  ;  the  back  is  anterior,  and  the 
head  is  in  the  left  iliac  fossa.  The  operator  is  upon  the  woman's  right 
side,  and  his  right  hand  is  placed  upon  the  foetal  head,  while  the  left  is 
applied  to  the  other  end  of  the  foetal  ovoid  ;  the  arrows  indicate  the 
direction  in  which  the  two  ends  of  the  foetal  ovoid  are  caused  to  move, 
the  head  descending  to  the  pelvic  inlet,  the  breech  ascending  to  the 
uterine  fundus ;  when,  by  the  action  of  the  hands  in  concert,  the  change 

1  Hicks's  first  publication  upon  combined  external  and  internal  version  was  in  the  Lancet,  July. 
1860. 

2  London  Obstetrical  Societies  Transactions,  vol.  v.,  for  the  year  1863. 

3  It  seems  to  me  unfortunate  that  some  obstetric  writers  substitute  for  this  term  bipolar,  for 
confusion  may  thence  arise,  and  moreover  the  new  designation  is  incorrect,  for  when  in  ceph- 
alic version  by  internal  and  external   manipulation  the  fingers  or  hand  are  applied  to  the 
shoulder,  that  is  not  one  of  the  poles  of  the  foetal  ovoid  ;  or,  again,  when,  as  in  a  part  of  Hicks's 
method,  just  described,  the  head  is  made  to  "  play  like  a  ball  between  the  two  hands,"  those 
hands  are  not  at  the  poles  of  the  ovoid.    There  is  not  a  step  in  the  entire  process  that  can  be  cor- 
rectly termed  bipolar. 


584 


THE  PATHOLOGY  OF  LABOR. 


in  the  position  of  the  foetus  has  been  effected  so  that  the  head  is  at  the 
inlet,  Wigand's  direction  is  followed,  and  she  lies  upon  her  left  side,  that 
is,  upon  the  side  toward  which  the  head  was  displaced.  If  labor  has 
begun,  again  following  the  direction  of  Wigaud,  the  membranes  are 
ruptured  so  that  the  head  will  be  retained  in  its  normal  position  by 
uterine  contractions ;  if  labor  has  not  begun,  the  same  object  is  sought 
by  the  application  of  a  bandage ;  one  has  been  devised  by  Pinard  for 
this  purpose. 

PELVIC  AND  PODALIC  VERSION.  Pelvic  version  by  external  man- 
oeuvres is  indicated,  according  to  Klein wachter,  whenever  the  pelvis 
lies  nearer  the  inlet  than  the  head  does.  It  may  be  done  during  labor 
or  in  pregnancy.  The  manipulation  is  similar  to  that  which  has  just 
been  described  as  employed  in  cephalic  version.  But  as  a  vertex  pre- 
sentation can  be  secured  in  the  condition  just  stated  with  little  more 
trouble,  and  as  this  is  so  much  more  favorable,  pelvic  version  will  rarely 
be  employed. 

FIG.  225. 


BRAXTON  HICKS'S  METHOD  OF  COMBINED  PODALIC  VERSION,  FIRST  STAGE. 

One  or  two  fingers  of  the  left  hand  lift  the  head  from  the  hrim  and  push  it  toward  the  left  iliac 

fossa,  while  the  right  hand  pushes  the  breech  transversely  toward  the  right  side. 

PODALIC  VERSION  BY  BRAXTON  HICKS'S  METHOD.     This  method 
will  be  presented  in  the  author's  words,  and  with  his  illustrations. 
The  patient  occupies  the  left  lateral  position.     The  os  uteri  is  sup- 


OBSTETRIC  OPERA  TIG  AS. 


585 


posed  to  be  dilated  so  that  one  or  two  fingers  can  enter,  and  the  mem- 
branes unruptured,  and  the  face  toward  the  right  side. 

"  Having  lubricated  my  left  hand,  I  introduce  it  as  far  into  the 
vagina  as  is  necessary  in  order  to  reach  a  finger's  length  within  the 
cervix — sometimes  it  requires  the  whole  hand,  sometimes  three  or  four 
fingers  will  be  sufficient  in  the  vagina.  Having  clearly  made  out  the 
head  and  its  direction,  whether  to  one  side  or  the  other  of  the  os  uteri, 
I  place  my  right  hand  on  the  abdomen  of  the  patient,  toward  the  fun- 
dus ;  I  then  endeavor  to  make  out  the  breech,  which  is  seldom  a  diffi- 
cult matter.  The  external  hand  then  presses  gently  but  firmly  the 
breech  to  the  right  side ;  as  it  recedes,  so  the  hand  follows  it  by  gentle 
palpation,  or  by  a  kind  of  gliding  movement  over  the  integuments, 
while  at  the  same  time  the  other  hand  pushes  up  the  head  in  the  oppo- 
site direction,  so  as  to  raise  it  above  the  brim  (Fig.  225). 


FIG.  226. 


BRAXTON  HICKS'S  METHOD,  SECOND  STAGE. 

The  left  hand  pushes  the  shoulder  to  the  left,  while  the  right  hand  pushes  the  breech 
to  the  right  and  downward. 

"  It  may  here  be  mentioned  that  when  the  head  has  descended  a  con- 
siderable distance  into  the  pelvic  cavity,  or  more  than  half-way  through 
the  os  uteri,  it  is  scarcely  possible  to  lift  it  above  the  brim,  especially  if 
the  uterus  be  active. 

"  When  the  breech  has  arrived  at  or  about  the  transverse  diameter  of 
the  uterus,  the  head  will  have  cleared  the  brim,  and  the  shoulder  will 
be  opposite  the  os  (Fig.  226).  That  is  pushed  on  in  like  manner  at  the 


586  THE  PATHOLOGY  OF  LABOR. 

head,  and  after  a  little  further  depression  of  the  breech  from  the  outside 
the  knee  touches  the  finger  and  can  be  hooked  down  by  it  (Fig.  227). 
It  very  frequently  happens  when  the  membranes  are  perfect  that  as 
soon  as  the  shoulder  is  felt,  the  breech  and  foot  come  to  the  os  in  a 
moment,  in  consequence  of  the  tendency  of  the  uterus  to  bring  the  long 
axis  of  the  child  coincident  with  that  of  its  own.  Should  it,  therefore, 
be  difficult  to  hook  down  the  knee,  depress  the  breech  still  more,  and  it 
will  almost  always  be  the  case  that  the  foot  will  be  at  hand. 

FIG.  227. 


BRAXTON  HICKS'S  METHOD. 

The  right  hand  forces  the  foetal  limb  down  within  reach  of  the  left  hand,  so  that  the 
fingers  may  be  hooked  over  the  knee. 

"It  will  sometimes  render  turning  more  easy  if,  as  soon  as  the  head 
is  above  the  brim,  we  pass  the  outside  hand  beneath  it,  and  push  it  up 
from  the  outside  alternately  with  the  depression  of  the  breech.  All 
this  can  generally  be  performed  in  a  much  less  time  than  I  have  taken 
to  describe  it,  although  in  some  it  requires  gentle,  firm,  and  steady  per- 
severance, with  such  a  supply  of  patience  as  is  always  required  in 
obstetric  operations." 

DIRECT  PODALIC  VERSION,  OR  INTERNAL,  TURNING.  This  is  the 
method  of  turning  that  is  most  frequently  employed.  In  its  considera- 
tion there  will  be  presented  in  order  the  necessary  conditions  permitting 
it,  the  indications  requiring  it,  and  the  way  in  which  it  is  done. 

In  order  that  podalic  version  may  succeed  the  os  must  be  sufficiently 
dilated  to  permit  the  entrance  of  the  hand,  the  presenting  part  of  the 
foetus  must  be  mobile,  and  the  pelvis  of  a  size  permitting  birth. 

The  indications  for  podalic  version  are,  first,  unfavorable  presenta- 
tion. Under  this  will  be  included  not  only  presentation  of  the  shoulder 
— probably  the  condition  most  frequently  requiring  turning — but  also 


OBSTETRIC  OPERATIONS.  587 

presentatiou  of  the  posterior  parietal  bone,  presentation  of  the  forehead, 
or  of  the  face,  if  the  chin  is  posterior,  and  complex  presentations,  for 
example,  a  member  descending  with  the  head,  or  the  umbilical  cord;  in 
some  instances  the  indication  for  turning  is  absolute,  but  in  others  only 
conditional.  In  double  monstrosities,  podalic  version  will  usually  be 
indicated. 

Podalic  version,  whether  by  direct  or  indirect  method,  is  indicated 
in  certain  dangerous  conditions  for  mother  or  child,  e.  g.,  in  accidental 
or  unavoidable  hemorrhage,  in  compression  of  a  prolapsed  cord,  when 
delivery  can  thereby  be  more  promptly  accomplished. 

Finally,  podalic  version  is  employed  in  cases  of  flat  pelvis  in  certain 
conditions.  On  page  508  this  turning  is  referred  to  as  advisable  when 
the  head  fails  to  engage.  But,  in  addition,  prophylactic  turning  has 
been  advocated  by  many  obstetricians  as  the  proper  treatment  in  this 
deformity  of  the  pelvis,  and  Kaltenbach  has  added  to  the  flat  pelvis  the 
obliquely  distorted  pelvis. 

Of  course,  this  was  the  method  of  treating  delayed  and  difficult  labor  long 
ago ;  but  it  is  especially  to  the  investigations  and  the  writings  of  the  late  Sir 
James  Y.  Simpson  that  general  attention  has  been  directed  to  the  subject  in  this 
century.1  According  to  Sir  James,  not  merely  was  the  child  a  cone,  the  feet 
being  the  apex,  and  the  arch  or  biparietal  diameter  the  base,  but  also  the  head 
itself  was  cone-shaped,  the  base  of  the  skull  considerably  narrower  than  the 
arch,  the  bimastoid  diameter  being  notably  less  than  the  biparietal,  "  so  that  the 
cranium  increases  gradually  in  breadth  and  size,  like  the  whole  body,  from  below 
upward." 

Accepting  this  view,  it  is  obvious  that  if  the  head  comes  last  the  narrowest 
part  of  the  cone  enters  the  narrowest  part  of  the  pelvis  first,  while  the  broadest 
part  of  the  former  will  follow,  at  the  same  time  its  diameter  diminished  by  the 
overriding  of  the  parietal  bones.  Further,  it  is  regarded  as  favorable  that  the 
body  of  the  child  furnishes  an  "excellent  handle"  for  extracting  the  child, 
drawing  the  head  through  the  contracted  brim. 

The  cases  adapted  for  prophylactic  turning  are,  according  to  Runge,  those  in 
which  the  os  half,  or  more,  dilated,  the  head  remains  still  above  the  brim,  the 
patients  having  previously  had  difficult  labors,  or  given  birth  to  dead  children 
— turn  in  these,  and  deliver  as  soon  as  possible.  In  order  that  this  may  be  done 
the  foetus  must  be  movable,  and  the  amnial  liquor  not  long  discharged.  Acting 
in  these  conditions,  many  children  will  be  saved  that  would  be  lost  in  cranial 
presentation.  Of  course,  the  prognosis  for  the  child  is  more  favorable  the  less 
the  pelvic  contraction.  "In  a  conjugate  of  7.5  cm.  and  under,  one  will  not 
always  certainly  succeed  in  drawing  the  head  through  the  narrowed  part  with- 
out injury." 

In  performing  podalic  version  the  patient  lies  across  the  bed,  legs 
flexed,  and  feet  resting  upon  two  chairs.  Of  course,  careful  antisepsis, 
both  subjective  and  objective,  is  employed  :  usually  anaesthesia.  The 
operator  sits,  or  he  may  be  standing,  between  the  patient's  limbs,  and 
introduces  in  the  vagina  that  hand  the  palm  of  which  corresponds  with 
the  abdominal  plane  of  the  foetus,  the  hand  being  in  a  conical  form  for 
introduction ;  it  is  turned  so  that  the  dorsal  surface  rests  upon  the  pos- 
terior vaginal  wall ;  the  conical  form  necessary  for  introduction  is  no 
longer  kept,  and  the  hand  is  passed  up  to  the  mouth  of  the  womb ;  in  case 
the  membranes  have  not  been  ruptured  this  should  now  be  done,  for  the 
practice  once  advised  by  some  obstetricians  not  to  do  this  until  the  hand 

1  Obstetric  Works,  vol.  i. 


588  THE  PATHOLOGY  OF  LABOR. 

has  ascended  so  far  in  the  womb  that  a  foot  can  be  felt,  presents  no  real 
advantages  and  exposes  to  some  dangers  both  immediate  and  remote ; 
of  course,  the  more  completely  the  amnial  liquor  is  retained  the  more 
readily  version  is  accomplished — "it  is  like  turning  a  body  floating  in 
a  bucket  of  water" — but  if  the  hand  enters  the  amnial  cavity  imme- 
diately after  the  rupture,  it  acts  as  a  plug  and  prevents  the  escape  of  auy 
considerable  amount  of  fluid.  The  search  for  the  feet  or  for  a  foot  is 
facilitated  by  the  action  of  the  free  hand  externally  pressing  upon  the 
uterus,  keeping  it  in  one  position,  and  especially  by  pushing  toward  the 
internal  hand  the  pelvis  of  the  child.  In  this  search  two  methods  have 
been  proposed,  the  one  known  as  the  German  and  the  other  as  the 
French ;  in  the  former  the  hand  is  passed  directly  to  the  anterior  plane 
of  the  fetus  and  then  to  the  part  where  the  feet  and  knees  are ;  by  the 
other  plan  the  hand  follows  the  lateral  plane  of  the  foetus  until  the 
lower  limb  is  found,  and  then  a  finger  may  be  hooked  behind  the  knee, 
and  the  latter  thus  drawn  to  the  mouth  of  the  womb  when  the  leg  is 
extended  and  the  foot  brought  into  the  vagina. 

The  objections  made  by  Hergott  to  the  German  plan,  which  he  admits  is  the 
more  rapid,  is  that  upon  the  anterior  plane  the  four  members,  hands  and  feet, 
forearms  and  legs,  arms  and  thigh,  are  situated  very  near  each  other,  and  some- 
times crossed,  so  that  difficulties  of  distinction  may  be  presented,  and  the  accouch- 
eur is  liable  to  bring  down  a  hand  instead  of  a  foot.  He  also  states,  however, 
that  one  is  often  compelled  to  do  as  he  can,  neglecting  the  rules  which  seem  the 
best  and  safest. 

In  regard  to  the  selection  of  the  foot  of  the  foetus — usually  only  one 
will  be  brought  down — and  means  of  securing  it,  the  reader  is  re- 
ferred to  pp.  328-330. 

When  the  foot  is  brought  into  the  vagina  a  noose  of  thick  muslin  may 
be  placed  around  the  ankle  so  as  to  have  a  secure  hold  by  which  traction 
can  be  exerted,  and  this  traction  be  outside  of  the  vagina,  the  latter 
being  a  point  of  essential  importance  when,  as  in  some  cases  of  transverse 
presentation,  the  head  cannot  be  dislodged,  either  by  external  pressure 
or  by  pulling  upon  the  foot,  and  the  hand  must  be  introduced  into  the 
vagina  to  push  it  up.  It  must  be  remembered  that  the  movement  given 
to  the  pelvic  end  of  the  foetal  ovoid  by  pulling  upon  one  or  both  feet  is 
to  be  assisted  by  a  corresponding  movement  impressed  upon  the  cephalic 
end  by  the  hand  pressing  on  it  through  the  abdominal  wall. 

If  podalic  version  be  required  in  shoulder  presentation,  when  the  arm 
has  prolapsed,  it  is  not  always  necessary  to  begin  by  returning  the  arm, 
but  a  noose  is  placed  upon  the  wrist  so  that  it  may  be  drawn  down  when 
the  chest  is  delivered,  preventing  its  ascension  by  the  side  of  the  head ; 
of  course,  when  the  prolapsed  arm  interferes  with  the  introduction  of 
the  operator's  hand,  the  former  should  be  pushed  up  in  the  anterior 
portion  of  the  vagina.  Turning  having  been  accomplished  the  delivery 
of  the  child  is,  in  most  cases,  left  to  uterine  action,  as  in  an  original 
pelvic  presentation.  But  if  traction  upon  the  limb  or  limbs  be  neces- 
sary, because  of  inefficiency  of  uterine  action  or  the  necessity  of  speedy 
delivery,  it  must  be  made  simultaneously  with  the  contraction  of  the 
uterus,  and  assisted  by  manual  pressure  upon  the  abdomen.  The  rules 
as  to  the  delivery  of  the  trunk  and  head,  the  care  of  the  cord,  and  the 
treatment  of  ascension  of  the  arm  or  arms  are  found  on  pp.  321-324. 


CHAPTEK   XI. 

THE    FORCEPS. 

THE  forceps  obstetncius,  known  because  of  its  great  value  as  simply 
the  forceps — asserted  by  Baudelocque  the  most  useful  of  all  surgical 
instruments — made  possible  the  rule  given  by  Hippocrates,  that  in  cer- 
tain difficult  labors  the  hands  should  be  applied  to  the  child's  head,  and 
extraction  made.  The  forceps  furnishes  artificial  hands  to  be  applied 
to  the  child's  head,  and  delivery  accomplished  without  injury  to  it,  thus 
making  possible  that  which  the  unarmed,  unaided  human  hands  could 
not  do.  Yet,  how  many  centuries  the  obstetrician  waited  for  the  ideal 
of  Hippocrates  to  be  made  real,  and  how  powerless  obstetric  art  in  cer- 
tain emergencies  until  this  was  accomplished  ! 

The  word  forceps,  plural  forcipes,  is  not  derived,  as  some  authorities 
have  stated,  from  fortiter  and  capiens,  or  capio,  that  is,  seizing  strongly, 
but  from  formus,  warm,  and  capio,  as  the  use  of  the  word  by  Virgil  and 
Ovid  in  describing  the  work  of  the  Cyclops  plainly  proves,  and  as  also 
shown  by  the  employment  by  other  writers  of  the  word  formucales, 
which  Scaligerhas  said  should  beformucapes,  as  a  synonym  for  forcipes.1 
Whatever  the  derivation,  all  understand  by  the  forceps  an  instrument 
which  with  safety  can  be  applied  to  the  head  of  the  child,  and  its 
delivery  effected,  assisting  the  forces  of  Nature  when  they  are  insufficient, 
or  replacing  them  if  absent. 

History  of  the  Invention  of  the  Forceps.  In  the  year  1569  William  Chamberlen, 
who,  it  is  believed,  was  a  medical  practitioner,  and  his  wife  with  their  family 
had  been  living  in  Paris,  but  they  were  compelled,  because  of  being  Huguenots,  to 
remove,  and  they  took  refuge  in  England.  Peter  Chamberlen,  a  son,  was  then 
about  ten  years  old,  and  growing  up  to  manhood,  became  a  medical  practi- 
tioner; he  was  the  inventor  of  the  forceps,  as  established  by  the  careful  researches2 
of  Dr.  Aveling.  The  date  of  the  invention  is  not  known,  but  it  probably  was  some 
time  in  the  last  of  the  sixteenth  or  the  first  of  the  seventeenth  century.  On  the 
next  page  a  representation  of  the  forceps  first  invented  is  given.  The  branches 
cross,  and  this  is  the  case  with  almost  all  forceps  made  since.  They  are  fastened 
by  a  screw.  The  Chamberlens  had  at  least  three  other  forceps  similarly  made, 
but  somewhat  improved  upon  this  model. 

The  invention  was  carefully  concealed  by  the  family,  at  least  three  generations 
of  which  were  represented  in  the  medical  profession.  In  1670  Hugh  Chamberlen, 
a  descendant  of  the  brother  of  the  inventor,  went  to  Paris,  hoping  to  sell  the 
forceps  for  "  10,000  ecus,"  about  six  thousand  dollars.  After  spending  some 
six  months,  his  negotiations  came  to  an  abrupt  close  by  his  failing  to  deliver 
a  woman  who  had  such  pelvic  deformity  that  Mauriceau,  then  in  the  height 
of  his  fame  as  an  obstetrician,  declared  could  only  be  delivered  by  the  Ccesarean 
operation.  The  latter,  who  we  may  be  sure  would  tell  the  worst  in  regard  to 
the  conduct  of  this  would-be  rival,  states  that  Chamberlen  asserted  he  could 
deliver  the  poor  woman  in  half  of  a  quarter  of  an  hour,  but  that  he  tried  for 
three  hours  without  stopping  except  to  take  breath,  uselessly  exhausting  his 

1  Dictionnaire  encyclopedique  des  Sciences  medicales,  Chereau's  article  upon  the  forceps. 

2  The  Chamberlens  and  the  Midwifery  Forceps. 


590 


THE  PATHOLOGY  OF  LABOR. 


strength  as  well  as  his  industry,  and  then  abandoned  his  efforts  when  he  saw 
that  the  patient  was  likely  to  die  on  his  hands.  The  post-mortem  examination 
of  the  woman,  who  lived  twenty-four  hours  after  Chamberlen's  attempt,  showed 
that  the  uterus  had  been  greatly  injured  by  the  instrument. 


FIG.  228. 


CHAMBERLEN'S  FORCEPS. 

In  a  few  days  Chamberlen  returned  to  England.  In  1693  he  went  to  Amster- 
dam, and  was  more  successful  in  his  efforts  to  dispose  of  his  secret  than  he  had 
been  in  Paris,  for  the  famous  Roonhuysen  became  its  purchaser.  The  latter 
associated  with  him  Euysch  and  Boelkman,  and  the  firm,  with  their  successors, 
seem  to  have  carried  on  for  several  years  a  successful  trade  in  the  forceps ;  this 
traffic  was  greatly  increased  by  the  original  purchasers  having  a  law  passed 
forbidding  any  to  practise  obstetrics  unless  first  examined  by  them,  and  then 
purchasing  the  secret.  The  baseness  of  those  who  thus  trafficked  in  the  forceps 
sank,  as  Kleinwachter  says,  still  lower  ;  for  in  some  cases  only  part  of  the  secret 
was  sold,  one  blade  of  the  forceps  being  given.  Roonhuysen  had  a  student 
named  Van  der  Swam,  who  had  been  with  him  several  years,  and  whom  he  had 

Sromised  to  teach  the  art  of  delivery,  but  had  failed  to  make  his  promise  good. 
ne  day  this  student  had,  by  a  fortunate  accident,  an  opportunity  to  see  the 
forceps  without  the  knowledge  of  his  preceptor.  He  made  drawings  of  it,  and 
let  a  friend  have  them  ;  that  friend  communicated  them  to  Peter  Rathlaw,  who 
coming  to  Amsterdam  to  practise  obstetrics,  had  been  rejected  by  the  Amsterdam 
examiners  because  he  refused  to  buy  the  secret.  Rathlaw  made  good  use  of  the 
knowledge  acquired  after  his  rejection,  for,  actuated  possibly  by  revenge,  he 
published  a  description  of  the  forceps  in  1747. 

FIG.  229. 


PALFYN'S  FORCEPS. 

In  1716  Jean  Palfyn,  of  Gand,  who  was  a  celebrated  surgeon,  presented  to  the 
Paris  Academy  an  instrument  devised  by  him,  consisting  of  two  parallel  blades, 
which  were  to  be  applied,  one  on  each  side,  to  the  foetal  head,  and  by  which 
extraction  was  to  be  then  made ;  they  were  known  as  the  Palfynian  hands, 
Manus  Palfyniana.  Different  devices  were  used  for  fastening  the  hands  together 
after  their  introduction — Heister,  among  others,  attempted  thus  to  make  the 
instrument  useful,  but  failed — the  instrument  was  not  successful.  Still  it  repre- 
sented an  idea  in  the  construction  of  the  obstetric  forceps  which  a  hundred  years 
after  was  made  practical,  and  which  an  obstetrician  of  the  present  day,  Chassaig- 
nay,  has  sought  to  realize,  regarding  it  as  of  great  importance  that  the  branches 
of  the  instrument  should  be  parallel  instead  of  crossing. 


THE  FORCEPS.  591 

The  celebrated  obstetrician  La  Motte  had  Palfyn's  instrument  described  to 
him  by  a  friend  at  Paris,  and  he  declared  that  it  was  as  impossible  to  use  it  suc- 
cessfully as  it  would  be  to  pass  a  cable  through  the  eye  of  a  needle. 

In  1734  Mr.  Alexander  Butter,  surgeon  in  Edinburgh,  published  an  account 
"  of  a  forceps  used  by  Mr.  Duse,  who  practised  midwifery  in  Paris,"  stating  that 
it  was  "  scarce  known  in  this  country,  though  Mr.  Chapman  tells  us  it  was  long 
made  use  of  by  Dr.  Chamberlen,  who  kept  the  form  of  it  a  secret,  as  Mr.  Chap- 
man also  does."  Nevertheless,  "  Chapman,  in  1733,  published  a  description  and 
plate  of  the  instrument,  which  he  had  used  from  the  year  1726,  stating  it  to  be 
the  instrument  used  by  the  Chamberlens,  but  without  stating  whence  he  had 
procured  it."  (Churchill.)  It  also  appears  that  Drinkwater,  of  Brentford, 
"surgeon  and  man-midwife,"  who  began  practice  in  1668, and  died  in  1728,  had 
similar  forceps.  From  the  time  of  the  publication  by  Chapman  the  Chamber- 
len forceps  became  the  property  of  the  profession. 

The  conduct  of  the  Chamberlens  in  keeping  the  forceps  a  family  secret  has 
met  with  general  professional  condemnation.  Recently,  however,  some  voices 
have  been  lifted  up,  if  not  in  defence,  at  least  in  palliation  of  their  conduct, 
Aveling,  for  example,  saying  that  it  is  not  fair  to  judge  members  of  the  profes- 
sion who  lived  two  hundred  years  ago  by  the  code  of  ethics  which  medical  men 
now  accept ;  and  Poullet  promptly  adds  that  those  who  condemn  the  Chamber- 
lens  commit  an  anachronism. 

Right  must  have  some  firmer  foundation  than  the  shifting  sands  of  public 
opinion  ;  "  ought  is  an  ethical  atom,''  not  merely  in  the  fact  that  it  is  an  ultimate 
defying  analysis,  but  that  it  remains  always  the  same  ;  human  standards  of  right 
and  wrong  may  vary  with  knowledge,  with  conventionalities,  and  the  prevailing 
sentiment  of  the  times  ;  nevertheless,  none  nor  all  of  these  can  make  that  right 
which  is  essentially  wrong.  The  ethical  rule  which  governed  the  conduct  of 
the  Chamberlens  was  not  found  in  the  teaching  of  Hippocrates,  and  no  one  for 
a  moment  can  suppose  that  if  Sydenham  or  Harvey  had  invented  the  forceps, 
and  learned  its  great  value  for  the  saving  of  human  life  and  the  relief  of  human 
suffering,  either  would  have  kept  it  secret,  but  rather  would  have  hastened  to 
proclaim  the  instrument  and  its  importance  to  the  profession.  The  general 
verdict  of  the  profession  upon  the  conduct  of  the  Chamberlens  had  better  remain 
undisturbed. 

VARIETIES  OF  FORCEPS.  Kleinwachter  states  that  at  the  begin- 
ning of  the  present  century  every  professor  thought  it  important  he 
should  devise  a  new  forceps,  which,  of  course,  when  made,  received  his 
name.  This  ambition  has  not  been  limited  to  obstetric  teachers,  nor  is 
it  yet  extinct.  The  profession  has  thus  had  forceps  almost  innumerable 
— some  long,  some  short,  some  with  narrow  blades  for  introduction  in 
the  only  partially  dilated  os  ;  others  with  asymmetrical  blades  for  sacro- 
pubic  application  ;  some  of  "  gigantic  volume,"  dangerous  alike  to  the 
mother  and  the  foetus  ;  a  few  physicians  have  invented  what  Delore  has 
called  microscopic,  or  pocket  forceps — mere  toys,  or  at  least  capable  of 
meeting  only  the  most  trivial  needs. 

Undoubtedly  hundreds  of  obsletric  forceps  have  been  devised,  but,  in 
regard  to  each  one  of  the  majority  of  these  hundreds,  only  a  single 
instrument  has  been  made,  and  that  for  the  inventor.  In  some  in- 
stances the  new  forceps  which  gave  fame  to  the  inventor  never  existed, 
probably,  save  in  the  form  of  a  drawing,1  nevertheless,  drawing  and 
description  have  been  published  of  the  author's  instrument. 

Velpeau  wisely  remarked  that  very  many  of  the  alleged  improve- 
ments in  the  forceps  have  been  made  by  young  men  who  have  not  yet 

1  The  writer  happens  to  know  of  a  treatise  on  obstetrics  in  which  the  author  gives  a  represen- 
tation of  his  forceps,  and  yet  the  instrument  never  advanced  beyond  this  primary  condition  ;  it 
exists  only  as  a  drawing. 


592 


THE  PATHOLOGY  OF  LABOR. 


learned  that  in  all  surgical  operations  much  less  depends  upon  the  form 
of  the  instrument  than  upon  the  skill  and  ability  of  the  man. 

The  most  important  improvement  in  the  Chamberlen  instrument  was 
that  made  by  Levret,  the  addition  of  the  pelvic  curve;  he  presented  his 
"  new  curved  forceps "  to  the  Royal  Academy  of  Surgery,  Paris,  in 
January,  1747.  It  was  not  until  after  1751  that  the  great  British 
obstetrician,  Smellie,  speaks  of  using  the  pelvic  curve  in  his  instrument. 
Pugh,  a  contemporary  of  Smellie,  a  practitioner  at  Chelmsford,  England, 
published  in  1754  the  statement  that  he  had  invented  the  pelvic  curve 
in  1740.  But  professional  opinion  cheerfully  concedes  priority  in  the 
invention  to  Levret,  because  of  priority  of  publication. 

PIG.  230. 


HODGE'S  FORCEPS. 

Obstetricians  universally  accept  the  advantages  of  the  pelvic  curve. 
Not  so,  however,  with  the  next  great  improvement  in  the  instrument, 
that  of  Tarnier  (1877),  by  which  traction  is  made  in  the  axis  of  the 
birth-canal,  some  regarding  the  axis-traction  forceps — chief  among  them 
is  Pajot — as  no  advance  upon  the  old  instrument.  A  few  obstetricians, 
especially  those  of  Lyons,  have  insisted  upon  the  importance  of  the 
branches  being,  as  in  the  forceps  of  Palfyn,  parallel,  instead  of  crossed. 

DESCRIPTION  OF  THE  FORCEPS.  The  short,  straight  forceps,  which 
never  was  much  used  in  this  country,  and  which  has  fewer  advocates 
abroad,  in  Great  Britain  or  Ireland,  than  it  had  even  twenty  years  ago, 
will  not  be  considered  in  this  description,  the  ordinary  long  forceps  only 
being  referred  to.  This  consists  of  two  halves,  known  as  branches  or 


THE  FORCEPS. 


593 


arms,  these  branches  being  distinguished  as  right  and  left.  A  funda- 
mental law  governing  their  application  gives  rise  to  these  names  ;  thus 
the  left  branch  is  held  in  the  obstetrician's  left  hand,  and  introduced  in 
the  left  side  of  the  mother's  pelvis,  while  the  right  branch  is  held  in  the 
right  hand,  and  introduced  in  the  right  side  of  the  pelvis — and  this 
is  the  only  unchangeable  law  in  the  application  of  the  forceps.  The 
instrument  is  made  of  steel,  and  the  blade  should  have  some  elasticity, 
but  not  the  least  flexibility  ;  the  surface  should  be  smooth  and  polished, 
so  as  to  be  readily  and  thoroughly  cleaned ;  the  gutta-percha  covered 
instruments  ought  to  be  rejected,  for,  in  spite  of  all  care,  the  covering 
will  be  broken,  and  the  roughened  surface  thus  left  will  be  a  most 
inviting  lurking-place  for  septic  poison.  Each  branch  is  divided  into 
a  handle,  an  articulating  portion  or  joint,  and  a  blade.  The  handle 
must  be  shorter  than  the  blade,  lest  too  much  power  of  compression  be 

FIG.  231. 


SIMPSON'S  FORCEPS. 


given  the  instrument.  In  many  forceps  the  handle  ends  externally  in 
a  blunt  hook,  which,  in  rare  emergencies,  may  be  of  value,  but  often 
proves  an  inconvenience,  and  can  very  well  be  omitted.  The  handles 
should  be  covered  upon  their  external  side  with  ivory  or  ebony,  this 
being  grooved  or  notched,  so  that  they  may  be  firmly  grasped.  In  some 
instruments,  Simpson's  for  example,  each  handle  has  near  the  lock  a 
transverse  projection,  or  shoulder,  so  that  two  fingers  can  be  placed  over 
these  when  traction  is  made ;  a  similar  addition  can  be  usefully  made 
to  the  Davis  forceps,  and  thus  not  only  a  convenient  method  for  traction 
is  secured,  but  avoidance  of  too  great  compression  of  the  head,  which 
might  occur,  at  least  with  some  forceps,  when  the  handles  are  firmly 

f rasped.  In  Bedford's  forceps  rings  take  the  place  of  shoulders  in 
impson's.  The  lock  may  be  a  fixed  button  or  tenon  upon  one  branch, 
which  accurately  fits  into  a  mortise  or  depression  in  the  other  ;  or  there 
may  be  a  screw  which,  after  locking,  can  by  a  few  turns  be  made  to 
fasten  the  branches  more  firmly  together  ;  or  that  which  is  known  as 
the  English  lock,  as  seen  in  the  illustration  of  Simpson's  instrument, 
the  one  branch  notched  just  beyond  the  shoulder,  and  into  this  notch  a 
narrowed  part  of  the  other  fits. 

The  blade  is  fenestrated,1  thus  making  it  lighter  and  securing  better 

1  An  exception  to  this  rule  is  given  by  Hecker's  forceps — the  blades  having  no  fenestra. 


594  THE  PATHOLOGY  OF  LABOR. 

adaptation  to  the  fcetal  head ;  the  fenestra  has  somewhat  the  form  of  an 
elongated  oval,  and  both  the  external  and  internal  margins  of  the  blade 
are  bevelled.  Looking  at  the  branches  when  locked,  it  will  be  seen 
that  each  blade  presents  above  a  concavity,  below  a  convexity  ;  this 
curve  was  called  by  Levret  the  new  curve,  but  is  generally  known  as 
the  pelvic  curve ;  it  adds  greatly  to  the  facility  of  applying  the  instru- 
ment when  the  head  is  in  the  pelvic  cavity,  or  at  the  inlet,  and  to  its 
efficiency.  Another  curve  which  all  forceps  have  in  common  with  that 
originally  invented,  is  called  the  cephalic  curve  ;  each  blade  is  concave 
internally,  but  convex  externally  ;  the  blades  thus  fit  closely  upon  the 
fcetal  head,  and  at  the  same  time  occupy  the  least  space.  In  no  forceps 
is  this  curve  better  adapted  to  the  sides  of  the  fcetal  head  than  in  the 
Davis  instrument.  When  the  branches  of  the  forceps  are  united  the 
points  of  the  blades  should  not  touch,  but  be  at  least  half  an  inch  apart ; 
the  distance  between  the  blades  themselves  varies  in  different  instru- 
ments ;  thus,  it  is  three  inches  in  Simpson's,  two  inches  and  a  half  in 
Hodge's,  and  two  and  a  fourth  in  Davis's.  It  should  be  remembered 
that  this  measurement  is  made  between  the  two  opposite  most  distant 
points  of  the  margins  of  the  blades. 

FIG.  232. 


THE  DAVIS  FORCEPS  WITH  SHOULDERS  ON  HANDLES. 

Forceps  vary  in  length,  and  even  the  same  forceps  varies  as  furnished  by  dif- 
ferent makers.  In  illustration  of  the  latter  point,  I  have  three  of  the  so-called 
Davis  forceps,  procured  from  three  different  dealers  ;  one  of  the  instruments  is 
less  than  eleven  inches  in  length,  while  the  second  is  thirteen,  and  the  third  is 
fourteen  inches  long  ;  the  first  instrument,  though  procured  from  a  leading  New 
York  house,  is  coarse,  heavy,  and  does  great  injustice  to  one  of  the  best  of 
obstetric  forceps,  while  the  second  is  modelled  in  all  essentials  after  the  forceps 
used  by  the  late  Professor  Meigs,  weighs  but  ten  ounces  and  a  half,  and  is 
adequate  to  almost  every  case  in  which  forceps  delivery  is  advisable.  The 
Hodge  forceps  is  sixteen  inches  long,  that  of  the  late  Dr.  Wallace,  fifteen 
inches  ;  Braun's  Simpson,  fourteen  inches ;  Elliot's,  fifteen  inches ;  Robertson's, 
thirteen  inches  and  a  half;  Barnes's,  fifteen  inches;  Pajot's  forceps  is  forty-five 
centimetres,  and  Stoltz's  forty-two,  the  same  length  as  Levret's. 

The  forceps  represented  (Fig.  234)  is  that  of  Dr.  Joseph  Holt,  of  New  Orleans, 
formerly  Professor  of  Obstetrics  in  the  New  Orleans  School  of  Medicine.  This 
instrument  is,  I  believe,  used  by  many  Southern  practitioners.  Its  inventor 
presents  the  following  claims  in  its  behalf: 

"  A  minimum  weight  of  metal  compatible  with  full  efficiency.  Such  a  dis- 
tribution of  the  metal  as  shall  insure  resistance  and  compressing  power  where 
these  are  especially  required,  elasticity  where  required,  and  all  in  proportion. 
The  pelvic  curvature  is  in  actual  correspondence  with  the  curve  of  Carus, 
whereby  the  instrument  can  be  applied  at  the  superior  strait,  or  even  above  the 
brim,  as  easily  as  at  the  pelvic  floor.  On  account  of  this  curvature,  the  head  at 
the  brim  can  be  pushed  downward  and  backward  in  the  direct  axis  of  the 
superior  strait  as  surely  as  it  may  be  drawn  down  with  a  Tarnier  forceps,  and 
that,  too,  with  all  the  power  of  which  a  man  is  capable,  certainly  enough  for  the 
safety  of  maternal  and  foetal  tissues.  It  can  accomplish  the  work  of  the  latter 


THE  FORCEPS. 


595 


instrument  without  any  of  its  complex  machinery.     Again,  this  curvature  in- 
sures the  points  at  no  time  pressing  upon  the  sacrum.     The  bowels  accurately 


FIG.  233 


WALLACE'S  FORCEPS. 
FIG.  234. 


HOLT'S  FOBCEPS. 


adjust  themselves  to  the  child's  head,  securing  uniform  and  general  distribution 
of  elastic  pressure.     The  points,  nearly  parallel  and  flat,  enable  the  blades  to  be 


596  THE  PATHOLOGY  OF  LABOR. 

passed,  insinuating  themselves  between  impacted  surfaces.  There  is  no  degree 
of  impaction  that  will  not  permit  the  instrument  to  be  applied  without  force,  as 
abundantly  proved  in  practice.  Being  on,  the  points  compress  gently,  but  never 
injure ;  this  peculiar  modification  in  the  points  was  introduced  many  years  ago 
by  Dr.  Warrington,  of  Philadelphia." 

Fig.  235  is  a  representation  of  the  forceps  invented  by  Prof.  T.  A.  Reamy,  of 
the  Medical  College  of  Ohio. 


KEAMY'S  FORCEPS. 
FIG.  236. 


MILLER'S  FORCEPS. 


Fig.  236  represents  the  forceps  of  Dr.  DeLaskie  Miller,  formerly  Professor  of 
Obstetrics  in  Rush  Medical  College.  This  forceps  is  14|  inches  long,  the  width 
between  the  points  of  the  blades  f  of  an  inch,  the  blades  are  6|  inches  long  and 
3  inches  apart ;  the  handles  are  folding,  and  thus  the  instrument  made  more 
portable. 

POWERS  OF  THE  FORCEPS.  1.  A  dynamic  action  has  been  claimed 
for  this  instrument.  It  sometimes  happens  that  even  after  the  intro- 
duction of  a  single  blade  of  the  instrument  languishing  uterine  con- 
tractions are  quickened,  or  absent  ones  recalled,  and  so  much  importance 
was  attached  to  this  occasional  occurrence  that  Kilian  devised  a  galvanic 
forceps,  hoping  thus  to  increase  the  dynamic  power  of  the  instrument, 
but  the  experiment,  of  course,  failed.  The  obstetrician,  so  far  from 
seeing  any  quickening  effect  upon  uterine  and  abdominal  force  resulting 
from  the  application  of  the  forceps,  may  find  this  activity  entirely 


THE  FORCEPS.  597 

ceasing,  and   heuce   no  trust  can   be  put  in  a  dynamic  action  of  the 
instrument. 

2.  The  forceps  may  be  used  to  compress  the  fetal  head.     Experi- 
ments have  proved  that  the  diameter  compressed  can  be  reduced  to  a 
little   more  than  one-third  of  an  inch,  and  that  compression  carried 
beyond  this  is  liable  to  cause  fractures.     Moreover,  when  the  blades  are 
applied,  as  they  ought  always  to  be,  if  possible,  to  the  sides  of  the  child's 
head,  there  is  no  gain  in  compressing  any  of  the  transverse  diameters, 
as  there  is  no  hindrance  arising  from  any  of  these  being  too  great.     Still 
more,  if  the  biparietal  diameter  be  lessened  by  compression,  the  sub- 
occipito-bregmatic  is  increased,1  so  that  there  is  no  absolute,  or  only 
slight,  diminution  of  the  head-circumference.     Further,  such  compres- 
sion hinders  the  moulding  of  the  head,  by  which  nature  seeks  to  adapt 
it  to  the  canal  it  must  pass  through  ;  it  hinders,  too,  the  movements  of 
the  head  occurring  in  normal   labor.     That  a  particular  forceps  is  a 
powerful  compressor  is  not  a  commendation,  but  a  condemnation.     In 
traction   more  or  less  pressure  is  made  upon  the  head  -,  according  to 
Delore's  experiments,  the  pressure  perpendicularly  to  the  axis  of  the 
head  is  about  one-half  the  traction,  and  hence  there  is  a  relation  between 
the  force  of  traction  and  the  degree  of  compression.     Most  obstetricians 
regard  any  compression  beyond  that  which  is  required  to  prevent  the 
instrument  from  slipping  unnecessary,  and  it  may  be  injurious. 

3.  The  forceps  as  a  lever.     Notwithstanding  arguments  by  some, 
especially  by  Dr.   Mathews  Duncan  and  by  the  late  Dr.  Albert  H. 
Smith,  against  the  pendulum,  lateral,  or  oscillatory  movements  of  the 
forceps,  most  obstetricians  use  them  in  certain  conditions,  and  this  prac- 
tice is  indorsed  by  Delore  and  Berne.     The  former  states,  as  the  result 
of  his  experiments  made  with  the  dynamometer,  that  by  slight  oscilla- 
tory movements  great  differences  are  obtained,  which  may  vary  from 
twenty-five  to  sixty-five  kilogrammes,  when  strong  tractions  are  used. 
In  using  the  forceps  as  a  lever,  the  fulcrum  is  on  one  and  then  on  the 
other  side  of  the  birth-canal — or  one  of  the  hands  of  the  operator  may 
be  placed  externally  upon  one,  then  upon  the  other  side  of  the  vulval 
margin,  and  thus  be  made  the  fulcrum,  while   the  other  grasps  the 
handles — the  power  is  at  the  handles,  and   the   resistance  the  head, 
firmly  held  by  the  blades.     As  Spiegelberg  especially  enjoins,  traction 
should  always  be  associated  with  this  to-and-fro  movement,  a  movement 
which  should  be  gradual,  not  abrupt,  and  not  great,  and  should  only 
be  regarded  as  a  supplement  to  the  former  when  that  is  insufficient  to 
effect  delivery;  if  traction  be  not  made,  the  head  simply  see-saws  with 
the  lateral  movements,  the  fulcrum  on  each  side  not  advancing,  but 
constantly  remaining  the  same,  and  thus  no  progress  is  made  in  delivery. 

4.  The  forceps  used  to  effect  rotation.     It  not  unseldom  happens  that 
in  occipito-anterior  positions  the  introduction  of  the  posterior  blade  of 
the  forceps  causes  the  occiput  to  rotate  in  the  pubic  arch.     In  per- 
sistent occipito-posterior  positions  many  obstetricians  advocate  at  least 
the  attempt  to  produce  anterior  rotation  by  the  forceps. 

While  in  the  pendulum  movements  the  fulcrum  passes  down  in  a 

1  Recent  investigations,  which  will  be  mentioned,  seem  to  invalidate  this  statement;  but  they 
need  fuller  and  direct  confirmation  before  their  general  acceptance. 


598 


THE  PATHOLOGY  OF  LABOR. 


straight  Hue,  in  the  rotation  movements  it  moves  spirally.  Spiegelberg 
further  states  that  a  ring  so  tight  upon  the  finger  that  it  cannot  be 
removed  by  pulling  in  a  straight  line,  but  can  be  by  twisting  move- 
ments, or  partial  rotations,  is  an  imperfect  illustration  of  the  pendulum 
and  rotation  movements.  He  regards  rotation  movements  as  less  effi- 
cient, and  decidedly  more  dangerous  than  pendulum  movements,  but 
says  that  they  may  be  useful  when  the  position  of  the  head  is  not  known, 
as  indicating  the  right  direction  for  traction,  and  that  of  least  resistance. 
This  doctrine  should  be  accepted  not  without  hesitation,  and  yet,  coming 
from  such  eminent  authority,  not  be  rejected  without  just  consideration. 
But  in  general  the  use  of  the  forceps  as  a  rotator  is  only  exceptionally 
advisable,  and  frequently  then  the  attempt  is  only  an  attempt — simply 
an  experiment.1 

FIG.  237. 


TRACTION  WITH  THE  COMMON  FORCEPS. 

5.  The  forceps  as  a  tractor.  Having  thus  considered  the  doubtful  or 
occasional  powers  of  the  forceps,  or  powers  that  are  only  exceptionally 
required,  we  come  finally  to  the  essential  power  of  the  instrument,  that 
of  traction.  The  pulling  power  made  by  means  of  the  forceps  is  to  be 
considered  in  reference  to  the  force  exerted,  the  line  of  direction  of  the 
pull,  and  as  to  whether  this  traction  should  be  intermittent  or  con- 
tinuous. 

In  easy  labors  the  force  exerted  is  probably,  as  stated  by  Mathews 
Duncan,  little  more  than  equivalent  to  the  weight  of  the  child;  in 

1  Rotation  of  the  head  by  the  forcffps,  conjoined  with  manual  rotation  of  the  body,  Ostermann's 
method,  will  be  described  hereafter. 


THE  FORCEPS. 


599 


difficult  labors  it  is  very  much  greater,  possibly  amounting  to  fifty 
pounds,  and  in  forceps  delivery  it  is  in  some  cases  very  much  greater 
than  even  the  latter.  Delore  makes  the  following  statement  as  to  the 
force  that  can  be  used  with  the  forceps  :  A  man  without  support,  that 
is,  not  bracing  himself,  exerts  a  force  equal  to  88  pounds  ;  with  support, 
twice  as  much,  or  176  pounds,  the  same  as  two  men,  but  the  two  with 
support,  286  pounds.  Taruier  states,  and  the  statement  is  indorsed  by 
Delore,  that  it  is  scarcely  ever  necessary  to  use  a  force  exceeding  132 
pounds ;  more  than  this  is  dangerous.  According  to  Spiegelberg,  the 
pulling  should  be  done  with  the  forearms,  while  the  arms  rest  by  the 
sides  ;  there  is  usually  no  necessity  for  extending  the  arms,  still  less  for 
bracing  the  body  by  placing  the  feet  against  the  bed. 


FIG.  238. 


TRACTION  wifn  TARNIER'S  FORCEPS. 


It  is  universally  agreed  that  the  direction  of  the  pull  should  cor- 
respond with  the  axis  of  the  birth-canal.  But  what  is  that  axis  ? 
Obstetricians  for  a  time  held  that  it  was  represented  by  the  curve  of 
Carus,  and  then  a  parabolic  curve  was  substituted,  as  better  showing 
this  axis  ;  but  as  the  investigations,  first  of  Fabbri,  afterward  of 
Sabatier,  of  Piuard,  and  more  recently  of  Boissard,  and  of  Varnier, 
show,  the  obstetric  pelvis — the  dynamic  as  distinguished  from  the  static 
pelvis — the  soft  parts  being  appended  to  the  bony  pelvis,  and  those 
which  make  the  pelvic  floor,  thus  forming  the  entire  pelvis — presents  a 
cavity  which  is  not  in  any  respect  a  curved  canal,  but  approximates  the 


600 


THE  PATHOLOGY  OF  LABOR 
FIG.  239 


SMITH'S  METHOD  OF  MAKING  AXIS-TRACTION. 

form  of  a  cylinder,  having  two  walls,  anterior  and  posterior,  almost 
vertical,  and  at  the  fundus  forming  a  plane  nearly  perpendicular  to 
these  two  walls.  This  cylinder  has  its  fundus  at  the  coccyx,  and  an 
opening  upon  the  anterior  wall.  Now,  laying  aside  confusing  curves, 
pelvic  inclined  planes,  and  speculative  synclitisms,  the  head  descends  to 
the  pelvic  floor  in  a  straight  line,  then  turns  at  almost  a  right-angle  to 
make  its  exit  at  the  vulva  ;  in  other  words,  the  axis  of  the  birth-canal 

FIG.  240. 


PA  JOT'S  MANOEUVRE. 


THE  FORCEPS.  fiQl 

is  at  first  a  line  directed  backward  and  downward,  and  then  a  line 
almost  perpendicular  to  it.  Hence,  until  the  head  reaches  the  pelvic 
floor,  the  fund  us  of  the  pelvic  cylinder,  the  traction  with  the  forceps 
must  be  downward  and  backward,  and  then  upward  and  forward.1 
When  the  head  is  high  in  the  pelvic  cavity,  or  is  just  entering  the  inlet, 
pulling  downward  and  backward,  that  is,  in  the  axis  of  the  obstetric 
pelvis,  is  not  an  easy  task  ;  and  yet,  if  it  be  not  done,  there  is  a  great 
loss  of  power. 

FIG.  241. 


Two  FORMS  OF  HUBERT'S  FORCEPS  WITH  TRACTION-ARM  AT  RIGHT-ANGLE  TO  HANDLE. 

Now,  to  effect  such  traction,  many  obstetricians,  since  Osiander,  have 
resorted  to  pressure  downward  at  or  beyond  the  forceps  lock  with  one 
hand,  while  the  other  grasps  the  handles  near  their  end,  not  so  much 
for  making  traction  as  to  resist  the  downward  pressure  of  the  other 
hand,  and  thus  the  handles  become  a  lever  rather  than  a  means  by 
which  pulling  is  directly  done. 

Pajot's  method  is  the  following :  "  We  apply  the  left  hand  as  near 

1  The  reader  is  referred  to  page  45  for  the  views  of  Farabeuf  and  Varnier  as  to  the  lines  of  trac- 
tion in  the  use  of  the  forceps. 


602 


THE  PATHOLOGY  OF  LABOR. 


as  possible  to  the  vulva,  the  right  hand  near  the  end  of  the  handles  ; 
then  we  use  sometimes  these  two  hands  in  order  to  make  the  forceps,  at 
times  a  lever  of  the  first  order,  sometimes  of  the  third,  sometimes  a  lever 
and  a  tractor  at  the  same  time,  sometimes  a  direct  tractor,  according  to 
the  resistance  and  the  height  of  the  pelvis  at  which  they  are  found." 


FIG.  242. 


FIG.  243. 


TARNIEE'S  AXIS-TRACTION  FORCEPS. 


MCFERRAN'S  FORCEPS. 


Other  methods  of  securing  axis-traction  have  been  by  certain  changes 
of  the  forceps  itself  or  by  attaching  to  it,  at  or  near  the  blades,  traction- 
rods.  Hubert  (1860)  had  arms  projecting  from  the  under  surface  of 
each  handle  of  his  forceps.  Morales  gave  the  handles  of  his  instrument 
a  periueal  curve,  so  that  in  pulling  on  the  lower  portion  the  pull  was, 
theoretically  at  least,  in  the  axis  of  the  pelvis.  Hermann,  in  1840, 
applied  traction-rods  to  the  forceps  blades,  but  this  invention  seemed  to 
cause  no  attention  until  after  1877,  the  year  in  which  Taruier  first 
exhibited  his  own  forceps  with  a  similar  device.  Fig.  242  is  an 
illustration  of  Tarnier's  instrument,  not  as  originally  devised,  but  as 
subsequently  modified. 

Several  modifications  of  Tarnier's  instrument  have  been  made;  Simp- 
son's and  Lusk's,  for  example,  are  excellent;  other  axis-traction  for- 
ceps have  been  devised,  and  among  those  worthy  of  note  are  the  instru- 
ment of  McFerran,  of  Philadelphia,  and  that  of  Breus.  Though  many 


THE  FORCEPS.  603 

distinguished  obstetricians  have  hailed  the  forceps  of  Taruier  as 
marking  a  new  era  in  obstetrics,  and  as  being  the  only  important  change 
since  Levret  gave  the  forceps  the  pelvic  curve,  others,  chief  among 
whom  may  be  mentioned  Pajot,  prefer  the  old  instrument,  "  the  classic 
forceps."  Tarnier's  is  a  much  more  expensive  instrument  and  more 

FIG.  244.  FIG.  245. 


BREUS'S  AXIS-TRACTION  FORCEPS.  STKPHENSON'S  DEVICE  FOR  AXIS-TRACTION. 

complicated,  and  probably  never  will  supersede  the  old  forceps,  while  it 
presents  great  advantages  in  special  cases,  which,  however,  rarely  occur 
to  the  general  practitioner. 

Winckel  regards  Breus's  forceps  as  preferable  to  all  others  because  of 
lightness  of  the  instrument  and  the  facility  of  its  application. 

FIG.  246. 


KNOX'S  FORCEPS. 


604  THE  PATHOLOGY  OF  LABOR. 

Fig.  245  represents  the  forceps  of  Dr.  Stephenson,  Professor  of  Mid- 
wifery in  the  University  of  Aberdeen.  It  will  be  observed  that  axis- 
traction  is  sought  by  means  of  a  rod  hooked  in  front  of  the  lock.  This 
instrument  was  shown  at  the  Glasgow  meeting  of  the  British  Medical 
Association  in  1888. 

Fig.  246  represents  the  axis-traction  forceps  of  the  late  Dr.  J.  S. 
Knox,  of  Chicago. 

Poullet,  of  Lyons,  has  an  excellent  forceps  to  the  blades  of  which  he  attaches 
tapes,  and  these  in  turn  are  fastened  to  a  handle  for  pulling,  thus  seeking  to  ac- 
complish axis-traction.  No  one  who  tries  this  device  and  compares  the  facility 
of  employment,  and  efficiency  of  the  instrument,  after  having  used  Tarnier's 
forceps,  or  any  one  of  its  excellent  modifications,  will  for  a  moment  give  prefer- 
ence to  Poullet's  forceps  or  any  of  its  imitations. 

The  general  rule,  as  to  traction  with  the  forceps,  is  that  it  should  be 
intermittent — a  pull  and  a  pause — our  art  thus  an  imitation  of  nature, 
which  in  normal  labor  expels  the  child  by  intermittent,  not  by  continu- 
ous contractions.  Nevertheless.  Pinard  regards  slowness  of  traction  as 
more  important  than  iutermittence. 

INDICATIONS  FOR  THE  USE  OF  THE  FORCEPS.  The  forceps  is  alike 
the  mother's  and  the  child's  instrument,  and  the  indications  for  its  use 
may  be  summed  up  as,  whenever  the  life  of  either  requires  immediate 
delivery.  Thus,  on  the  part  of  the  mother,  convulsions,  hemorrhage, 
rupture  of  the  uterus,  excessive  feebleness,  threatened  asphyxia  from 
cardiac  or  pulmonary  disease,  arrest  of  the  progress  of  the  labor  from  peri- 
neal  resistance ;  on  the  part  of  the  foetus,  prolapse  of  the  cord,  com- 
plicated presentation,  sudden  death  of  the  mother,  feebleness  of  the 
cardiac  pulsations,  either  associated  with  great  slowness  or  frequency, 
showing  interference  with  the  utero-placental  circulation,  or  compression 
of  the  cord  may  be  present,  and  demand  instrumental  delivery.  May 
the  obstetrician  use  the  forceps  solely  for  the  purpose  of  shortening  the 
mother's  suffering  ?  Spiegelberg  admits  this  indication,  and  wisely  adds 
that  he  who  undertakes  such  "  luxus-operation  "  must  understand  how 
to  control  his  hands  intellectually  and  mechanically ;  but  this  is  not 
always  the  case,  and  the  intended  assistance  is  often  the  reverse. 

That  the  forceps  is  too  frequently  used  cannot  be  doubted,  and  that  in  conse- 
quence of  its  unnecessary  employment  many  times  the  perineum  has  been  torn, 
or  other  injury  been  done  the  mother.  It  probably  will  not  be  required  in  more 
than  5  or  6  per  cent,  of  cases  of  labor.  This  position  may  be  strengthened  by 
quoting  the  statistics  given  by  Winckel  and  those  of  Ahlfeld.  The  former,  in 
100,000  deliveries  at  various  clinics  in  Europe,  found  that  the  forceps  was  used 
in  4.6  per  cent,  of  all ;  the  latter  states  that  in  2900  births  in  the  Marburg  Ma- 
ternity, the  forceps  was  employed  only  81  times — that  is,  in  2  8  per  cent.  In 
the  clinic  of  Professor  v.  Rosthorn,  Prague,  there  were,  from  1891  to  1894 
inclusive,  2920  women  delivered,  and  the  forceps  used  in  3.63  per  cent. 

CONDITIONS  NECESSARY  FOR  THE  USE  OF  THE  FORCEPS.  1.  The 
forceps  is  to  be  applied  to  the  head  of  the  child ;  the  head  may  be  first 
or  last,  the  presentation  may  be  cranial  or  facial,  but  the  rule  is  to  apply 
the  forceps  blades  only  to  the  head. 

The  application  of  the  forceps  in  pelvic  presentation  was  probably  first  sug- 
gested by  Levret,  and  in  recent  years  Pajot  has  given  this  use  of  the  instrument 
a  qualified  approval  if  the  child  be  dead.  But  for  several  years  some  obstetri- 


THE  FORCEPS.  605 

cians  have  used  the  forceps  in  pelvic  presentations  when  the  child  was  living, 
and  sometimes  delivery  has  thus  been  safely  accomplished,  after  the  means 
usually  resorted  to  in  delayed  pelvic  deliveries  had  been  vainly  tried. 

While  probably  other  modes  of  artificial  delivery  in  pelvic  presentation  will 
be  usually  selected,  yet  the  operator,  if  expert  with  the  forceps,  need  not  hesi- 
tate to  use  it,  after  the  experience  of  Tarnier,  Lusk,  and  others ;  the  best  instru- 
ment, except,  of  course,  one  of  those  devised  for  the  purpose,  is  Tarnier's, 
because  of  its  unvarying  compression.  Nevertheless,  the  few  trials  which  I 
have  made  of  this  application  of  the  forceps  have  been  unsatisfactory. 

2.  The  mouth  of  the  womb   must   be'  completely  dilated,  or  so  far 
dilated  and  so  dilatable  that  the  blades  can  be  readily  introduced  and 
applied,   and    then   extraction    of   the    head    made   without  injury   to 
the   lower  segment  of  the   uterus ;  if  this   rule   be  neglected,  there  is 
danger  of  the  forceps  blades  tearing  the  neck  of  the  womb  as  they  are 
introduced,  or  else,  when  traction   is  made,  the  lower  uterine  segment 
will  be  dragged  down,  or  the  tissues  about  the  mouth  of  the  womb  be 
lacerated  or  seriously  bruised. 

Dubois  devised  forceps  with  narrow  blades  for  introduction  into  the 
partially  dilated  os,  but,  according  to  Tarnier,  the  results  were  bad. 
The  late  Dr.  Taylor,  of  New  York,  also  had  narrow-bladed  forceps  for 
similar  use. 

3.  The  head  must  be  of  normal  size  and  consistence.     A  small  or 
macerated  head  readily  slips  out  of  the  forceps  blades,  and  these  can- 
not be  sufficiently  approximated  if  the  head  be  very  large,  as,  for  ex- 
ample, in  hydrocephalus. 

FIG.  247. 


FORCEPS  OF  ASSAUNI. 


The  advocates  of  forceps  with  parallel  instead  of  crossed  branches 
claim  as  an  advantage  of  such  instrument  that  it  is  peculiarly  adapted 
to  large  heads,  grasping  these  with  such  firmuess,  and  yet  without  injury, 
that  extraction  can  be  more  readily  accomplished.  We  present  one  form 
of  the  forceps  with  parallel  blaojes. 

4.  The  birth-canal  must  present  no  serious  hindrance,  either  from 
pelvic  deformity  or  from  neoplasms,  to  the  passage  of  the  child.  The 
hindrance  most  frequently  arises  from  narrowing  of  the  pelvic  inlet, 
and  the  question  as  to  whether  podalic  version  or  the  application  of 
the  forceps  be  indicated,  is  one  in  regard  to  which  eminent  obstetric 
authorities  differ.  Barnes  makes  the  limit  in  the  pelvic  narrowing  as 
three  inches  and  a  fourth,  which  will  admit  of  the  useful  application  of 
the  forceps,  at  the  same  time  stating  that  a  head  slightly  below  the  nor- 
mal size,  and  less  firmly  ossified  than  usual,  may  be  brought  through  a 
conjugate  diameter  of  only  three  inches.  Pinard  holds  that  if  the  pel- 
vis measure  less  than  eight  centimetres,  the  infant  being  at  term  and 
presenting  normal  ossification  of  the  bones  of  the  head,  the  forceps  is 


606  THE  PATHOLOGY  OF  LABOR. 

not  to  be  applied  but  with  the  greatest  prudence ;  traction  should  be 
made  gently  and  slowly,  for  the  cases  of  exceptional  success  reported  by 
diiferent  authors  have  naturally  caused  excessive  tractions  which  could 
not  but  mutilate  the  fetus,  and,  further,  kill  both  mother  and  child. 

5.  Spiegelberg  made  the  condition  positive  that  the  head  has  passed 
the  inlet  by  its  greatest  periphery,  while  Pajot  regards  it  as  favorable 
for  the  application  of  the  forceps.  When  obstetricians  speak  of  the 
head  being  at  the  superior  strait  or  inlet,  they  do  not  mean  that  it  is 
just  at  its  entrance,  but  that  it  has  so  far  descended  the  parietal  pro- 
tuberances are  as  low  as  the  ilio-pectineal  line.  The  application  of 
the  forceps  when  the  head  is  movable  above  the  inlet  is  rejected  by  most 
obstetric  authorities,  podalic  version  being  preferred,  unless,  as  stated 
by  Charpentier,  the  uterus,  in  consequence  of  the  flow  of  the  amnial 
liquor,  is  strongly  contracted  upon  the  foetus,  rendering  version  im- 
possible, and  one  then  may  use  the  forceps.  Those  who  are  partial  to 
Tarnier's  axis-traction  forceps  regard  it  as  peculiarly  favorable  for  use 
when  the  head  is  high  up,  not  having  entered  the  pelvic  inlet.  Spiegel- 
berg  observed  that  such  application  when  the  head  is  high,  or,  perhaps, 
to  the  movable  head,  is  not  a  matter  of  indifference  for  mother  or  for 
child,  and  must  not  be  made  to  the  extent  that  many  claim.  Hodge 
regarded  "  fixation  of  the  head  and  its  partial  projection  through  the 
superior  strait"  as  "essential  prerequisites  for  the  operation  of  the  for- 
ceps." 

PREPARATIONS  FOR  USING  THE  FORCEPS.  There  are  but  few 
women  suffering  the  agony  of  childbirth  who  will  not  gladly  accept 
means  which  will  shorten  the  duration  of  that  agony ;  but  few,  when 
their  unborn  child  is  in  peril,  who  have  not  the  maternal  instinct  so 
strong  that  they  will  cheerfully  consent  to  the  use  of  the  forceps  to  avert 
that  peril.  It  is  unnecessary,  as  some  obstetric  authorities  have  recom- 
mended, to  show  the  patient  the  instrument;  if  foolish  and  timorous, 
she  will  not  be  thereby  reassured,  but  rather  have  her  fear  increased ; 
while  the  wise  and  courageous  are  willing  to  trust  their  physician. 
Delore  very  well  suggests  that,  if  it  happen  the  obstetrician  has  not 
his  forceps  with  him,  it  is  better  to  send  rather  than  to  go  for  the  instru- 
ment, lest  the  labor  end  in  his  absence. 

If  the  foetal  head  be  low,  and  only  the  resistance  of  the  vulvo- vaginal 
outlet  to  be  overcome,  the  patient  may  be  brought  to  the  foot  of  the  bed, 
the  lower  limbs  being  flexed ;  but  if  the  head  be  in  the  pelvic  cavity, 
or  at  the  inlet,  she  should  be  placed  across  the  bed,  her  hips  at  its  edge, 
and  each  foot  resting  on  a  chair,  while  each  knee  is  held  by  an  assistant. 
The  bladder  is  evacuated  by  a  catheter,  if  necessary,  for  the  use  of  the 
forceps  when  this  organ  is  full  may  cause  most  deplorable  injury  to  the 
vesico-vaginal  wall.  The  use  of  an  anaesthetic  is  advisable  in  most 
cases;  however,  this  may  usually  be  left  to  the  decision  of  the  patient, 
it  being  always  remembered  that  the  anaesthesia  is  obstetric,  not  surgi- 
cal. The  vagina  is  washed  out  with  an  antiseptic  solution.  The  ob- 
stetrician has  at  hand  hot  water  and  other  means  that  may  be  necessary 
if  the  child  happen  to  be  partially  asphyxiated,1  and  also  his  hypoder- 

1  Dr.  T.  G.  Davis,  of  Bridgeton,  N.  J.,  has  informed  me  of  his  success  with  the  recent  method  of 
rhythmic  traction  of  the  tongue  in  asphyxia  of  the  newborn.    "  I  seized  the  tongue  between  the 


THE  FORCEPS.  607 

matic  syringe,  sulphuric  ether,  and  a  liquid  preparation  of  ergot,  in  case 
the  condition  of  the  mother  after  delivery  should  require  either  of  the 
latter  two  to  be  given.  He  auscultates  the  fetal  heart,  and  thus  knows 
the  condition  of  the  child  ;  he  very  carefully  repeats  digital  vaginal  ex- 
amination, so  that  he  may  be  fully  assured  as  to  the  presenting  part  and 
its  position ;  and  if  any  doubt  remains,  let  him  introduce  his  hand  into 
the  vagina,  when  he  can,  by  feeling  the  ear  of  the  fetus  and  observing 
the  direction  of  its  convex  border,  at  once  know  both  presentation  and 
position.  He  will  require  at  least  two  assistants,  for  example,  the  nurse 
and  the  husband  of  the  patient ;  but  more  may  be  needed,  "  according 
to  the  difficulty  of  the  operation,  or  the  indocility  of  the  patient." 

OPERATION.  This  includes  three  acts :  (1)  the  introduction  of  the 
blades  of  the  forceps ;  (2)  locking  the  branches ;  and  (3)  extraction.  The 
instrument  having  been  first  made  aseptic  and  warmed  by  dipping  each 
branch  into  a  warm  solution  of  carbolic  acid  or  creolin  mixture,  the  ab- 
stetrician  applies  to  the  external  surface  of  each  blade  carbolized  cosmo- 
line,  vaseline,  or  oil,  and  similarly  anoints  the  fingers  of  his  right 
hand.1  As  locking  is  effected  when  the  right  branch  rests  upon  the 
left,  the  general  rule  is  to  introduce  the  left  blade  first — "  left  blade, 
held  in  the  left  hand,  and  always  passed  in  the  left  side  of  the  mother's 
pelvis" — and  accordingly  this  is  taken  in  the  left  hand,  the  thumb 
being  placed  upon  the  inner,  the  fingers  upon  the  outer  surface  near  the 
lock ;  the  grasp  should  be  firm,  secure,  but  gentle.  The  obstetrician 
takes  a  convenient  position,  for  example,  either  sitting  or  standing  be- 
tween the  patient's  knees,  if  she  be  lying  across  the  bed ;  introduces  two,  or 
if  the  head  be  high  up  four,  fingers  of  the  right  hand  into  the  vagina,  and 
if  possible  brings  their  tips  in  contact  with  the  margin  of  the  mouth  of 
the  womb,  and  thus  the  fingers  are  made  to  guide  the  course  of  the  for- 
ceps blade,  and  to  guard  the  maternal  parts,  saving  them  from  injury. 
The  point  of  the  blade  is  now  made  to  enter  the  vulval  orifice,  the 
handle  pointing  upward  and  to  the  right,  the  blade  "sinks  by  its  own 
weight  into  the  perineo-sacral  gutter,"  its  convexity  presses  against  the 
inner  surface  of  the  introduced  fingers,  its  concavity  adapts  itself  to  the 
foetal  head ;  with  the  ascent  of  the  blade,  which  should  be  assisted  by 
gentle  pressure  with  the  left  hand,  and  its  concave  surface  kept  in  con- 
tact with  the  fetal  head  by  the  fingers  of  the  right  hand,  the  handle  moves 
downward  and  to  the  left,  so  that  it  becomes  nearly  horizontal,  and  in 
the  median  line.  Here  the  question  arises,  should  the  forceps  be  ap- 
plied simply  transversely  with  reference  to  the  mother's  pelvis,  or  to 
the  sides  of  the  child's  head  ?  Many  British  and  German  obstetricians 
hold  to  the  former,  while  the  general  teaching  of  the  French  and  Ameri- 
can is  in  favor  of  the  latter.  Of  course,  when  the  head  is  low  and  in- 
ternal rotation  has  occurred,  the  mode  of  application  necessarily  meets 
both  requirements  ;  but  the  difference  of  methods  comes  when  the  head 
is  high.  The  arguments  in  favor  of  placing  the  blades  upon  the  sides 
of  the  child's  head  are,  that  the  sides  are  the  only  parts  that  are  sym~ 

thumb  and  index-linger  of  the  right  hand  and  made  rhythmic  traction,  at  the  same  time  the  left 
hand  beneath  the  back  of  the  chest  alternately  elevated  and  depressed  the  thorax  at  intervals 
corresponding  with  tractions  upon  the  tongue— twenty-four  a  minute.    After  twenty  minutes  the 
child  gasped,  and  in  about  thirty  minutes  breathed  and  cried." 
1  If  the  creolin  mixture  is  used,  ointment  or  oil  may  be  dispensed  with. 


608  THE  PATHOLOGY  OF  LABOR. 

metrical — the  only  parts,  if  labor  has  been  in  progress  for  some  time, 
that  lie  in  the  same  plane,  and  to  them  only  are  the  concavities  of  the 
blades  accurately  adapted.  The  last  remark  applies  especially  to  the 
Davis  forceps,  and  if  one  prefers  applying  the  forceps  transversely  in  the 
mother's  pelvis,  without  reference  to  the  position  of  the  foetal  head,  he 
will  select  an  instrument  having  a  wide  interval  between  the  blades, 
such  as  that  of  Simpson. 

Whichever  method  is  adopted,  the  obstetrician  bears  in  mind  that  the 
blade  is  to  be  introduced  gently,  not  forcibly — gliding,  feeling  its  way 
to  the  proper  place ;  decided  resistance  to  its  progress  proves  that  the 
direction  is  wrong,  and  therefore  must  be  changed ;  the  words  arte  non 
vi,  which  Blundell  suggested,  should  be  engraved  on  one  of  the  forceps 
blades,  should  not  be  forgotten  in  their  introduction. 

FIG.  248. 


INTRODUCTION  OF  THE  LEFT  BLADE  OF  THE  FORCEPS. 

After  the  first  blade  is  placed  in  position  its  handle  is  given  in  charge 
of  an  assistant,  while  the  obstetrician  introduces  the  second  blade.  The 
latter  takes  the  right  branch  in  his  right  hand — right  blade,  held  in  the 
right  hand,  and  introduced  into  the  right  side  of  the  mother's  pelvis — 
and  using  the  fingers  of  the  left  hand  in  a  similar  manner  and  for  the 
same  purpose  that  those  of  the  right  were  used  when  the  first  blade  was 
introduced,  the  second  is  placed  on  the  opposite  side  of  the  child's  head. 
When  the  operation  is  completed,  the  right  handle  rests  upon  the  left, 
and  they  are  usually  locked  without  difficulty.  Such  difficulty  may  oc- 
cur either  because  one  blade  has  been  introduced  farther  than  the  other, 
or  because  the  handles  are  not  in  the  same  plane.  The  difficulty  in  the 
first  case  is  removed  by  pushing  the  one  blade  farther  in,  or  slightly 
withdrawing  the  other.  If  the  handles  are  found  to  be  in  different 
planes,  each  handle  is  grasped  by  a  hand,  and  the  operator  gently  ro- 
tates the  blades  in  opposite  directions ;  if  this  fail  to  make  the  handles 
parallel,  the  second  blade  is  removed  and  reintroduced,  and  if  failure 
still  follow,  both  blades  must  be  taken  out,  and  the  effort  made  to  in- 
troduce them  so  that  the  proper  relation  shall  be  secured.  If,  with  some 


THE  FORCEPS.  (309 

difficulty  in  locking,  it  is  afterward  found  that  the  handles  cannot  be 
approximated,  but  stand  widely  apart,  this  may  result  from  the  head 
being  irregularly  grasped,  or  from  its  being  of  unusual  size,  or  from 
the  blades  not  having  been  passed  far  enough  over  the  head.  In  the 
last  case  it  often  happens  that,  if  the  handles  are  thus  left  without  effort 
to  bring  them  together — the  blades,  of  course,  being  correspondingly 
separated — a  few  vigorous  uterine  contractions  will  force  the  head 
farther  down  in  the  embrace  of  the  blades,  and  the  difficulty  is  ended. 
Irregular  seizure  of  the  head — as,  for  example,  that  in  which  an  oblique 
occipito-frontal  diameter  instead  of  the  biparietal  lies  in  the  transverse 
diameter  of  the  blades — is  necessary  in  some  cases ;  the  operator  recog- 
nizes this  condition,  and  makes  no  effort  to  force  the  handles  together, 

FIG.  249. 


INTRODUCTION  OF  THE  RIGHT  BI-ADK  OF  THE  FORCEPS. 

remembering  the  golden  rule  as  to  compression  ;  let  it  only  be  sufficient 
to  keep  the  instrument  from  slip'ping.  The  difficulty  in  approximating 
the  handles  is  always  great,  even  insuperable  in  case  of  a  very  large 
head,  and  it  is  possible  that  the  instrument  may  slip  after  the  most  care- 
ful application,  when  this  method  of  delivery  may  have  to  be  aban- 
doned. 

A  mistake  which  I  am  sure  is  not  infrequently  made,  is  failure  to  in- 
troduce the  blades  far  enough,  and  then,  for  example,  they  lie  in'  the 
direction  of  the  occipito-frontal  instead  of  the  occi  pi  to- mental  diameter. 

Care  must  be  taken  in  the  locking  that  hair  or  folds  of  skin  of  the 
external  genital  organs  are  not  caught  in  the  lock. 

The  readiness  with  which  locking  occurs,  the  approximation  of  the 
handles,  the  firmness  and  fixed  state  of  the  forceps,  the  instrument  and 

39 


610 


THE  PATHOLOGY  OF  LABOR. 


the  head  making  for  the  time  being  a  unit,  indicate  that  the  blades  are 
in  the  proper  position.  That  these  include  nothing  more  than  the  head — 
no  prolapsed  cord,  or  projecting  border  of  the  uterus,  and  no  vaginal 
fold — has  been  guarded  against  by  the  careful  manner  of  their  intro- 
duction ;  but  if  there  be  any  possibility  of  such  an  accident  having  oc- 
curred, the  sole  means  of  resolving  the  doubt  is  to  "  introduce  one  or 
two  fingers  to  the  level  of  the  blades,  as  well  in  front  as  behind." 

The  traction,  as  before  stated,  should,  as  a  rule,  be  intermittent ;  full 
force  must  not  be  employed  at  first ;  it  may  not  be  necessary  at  all,  but 
if  required  it  should  be  reached  gradually ;  pulling  with  the  forearms, 
or  with  one  of  them  at  first,  the  arms  being  by  the  side,  is  a  practice 
that  has  been  advised.  Usually,  if  the  power  be  given  the  right  direc- 
tion, it  need  not  be  great ;  in  rare  instances  the  accoucheur  has  to  exert 
considerable  force,  but  it  must  be  his  own,  unassisted  by  that  of  an- 
other. In  some  instances  the  operator  may  find  an  immediate  forceps 
delivery  carrying  greater  danger  to  the  mother  and  to  the  child,  or  both, 
than  will  a  delay  until  nature's  forces  have  moulded  the  foetal  head, 
thus  facilitating  the  transmission  through  the  birth-canal,  and  therefore 
the  effort  at  instrumental  delivery  must  be  postponed  until  such  mould- 
ing has  occurred. 

Fro.  250. 


PROTECTING  THE  PEKINEUM  IN  DELIVERY  WITH  THE  COMMON  FORCEPS. 

Should  the  forceps  be  removed  before  the  head  is  delivered?  Such  removal 
has  been  strongly  recommended  in  recent  years  by  Freund,  Goodell,  Lusk,  and 
others  and  was  the  practice  of  Taylor,  of  New  York,  for  many  years  before  his 
death.  It  is  the  revival  of  an  old  practice.  "Among  the  German  authors, 
Boer,  and  after  him  Joerg,  Carus,  and  others,  have  recommended  removing  the 
forceps  as  soon  as  the  head  is  engaged  in  the  vulva,  if  there  is  no  indication  for 
the  immediate  termination  of  the  delivery."  (Naegele  andGrenser.)  Madame 
Lachapelle  strongly  advocated  this  plan.  The  object  sought  by  the  removal  is 
to  prevent  injury  to  the  perineum  by  thus  taking  away  the  addition  to  the  head 
circumference  caused  by  the  blades  of  the  forceps.  The  objections  that  have 
been  made  to  this  practice  are,  that  while  the  accoucheur  is  removing  the  instru- 


THE  FOB  CEPS.  Gil 

ment  a  violent  contraction  may  suddenly  expel  the  head,  and  he  being  otherwise 
occupied,  is  powerless  to  give  any  protection  to  the  perineum  ;  or  nature's  forces, 
on  the  other  hand,  may  be  unequal  to  the  expulsion,  and  a  reapplication  of  the 
forceps  be  necessary.  Moreover,  we  have  in  the  forceps  the  best  means  of 
retarding  the  exit  of  the  head  until  the  vulvar  orifice  is  sufficiently  dilated,  and 
at  the  same  time  giving  it  proper  direction  when  that  exit  is  made  ;  the  forceps 
may  be  used  so  that  the  perineum  will  suffer  less  injury  than  in  normal  labor. 

FIG.  251. 


r 

PROTECTING  THE  PERINEUM  IN  DELIVERY  WITH  TARNIER'S  FORCEPS. 

After  this  general  consideration  of  the  application  of  the  forceps, 
next  will  be  presented  the  method  in  which  the  instrument  is  used  in 
different  presentations  and  positions. 

HEAD-FIRST  LABOR.  Cranial  Presentation,  and  (1)  Occipito-pubic 
Position.  In  this  position  the  head  was  so  small  that  it  entered  the 
inlet  with  its  occipito-frontal  diameter  in  relation  with  the  antero- 
posterior  of  the  former,  instead  of  with  one  of  the  obliques  or  the 
transverse;  or,  and  this  is  the  more  frequent  case,  anterior  rotation,  in- 
stead of  direct  descent,  has  placed  the  occiput  at  the  subpubic  ligament, 
or  in  the  pubic  arch.  The  blades  of  the  forceps  are  necessarily  placed 
in  direct  relation  with  the  sides 'of  the  mother's  pelvis,  and  upon  the 
sides  of  the  child's  head.  In  a  primipara  the  nearer  the  head  is  to  the 
vulvar  orifice,  the  more  difficult  the  introduction  of  the  guiding  fingers, 
but  this  introduction  need  go  no  further  than  the  parietal  protuberances, 
for  if  the  rim  of  the  os  uteri  has  cleared  these  it  has  retracted  as  far  as 
the  child's  neck  ;  passing  the  blades  deeply  in  is  unnecessary,  and  may 
do  serious  injury.  After  locking,  which  is  easily  done,  the  traction 
should  be  somewhat  downward  at  first,  if  the  occiput  has  not  come  in 
front  of  the  subpubic  ligament ;  but  if  it  has,  or  after  it  has  been 
brought  thus  in  front,  the  handles  are  gradually  raised  so  as  to  assist 
deflection,  the  occipital  end  of  the  long  head  diameter  being  outside  the 
pelvis,  and  the  normal  delivery  of  the  head  taking  place  by  a  rotation 


612  THE  PATHOLOGY  OF  LABOR. 

upon  its  transverse  axis  through  the  arc  of  a  circle,  suboccipital  diam- 
eters measuring  the  distance  from  the  lower  margin  of  the  pubic  joint 
to  the  anterior  margin  of  the  perineum.  Care  must  be  taken  to  ob- 
serve this  normal  mechanism  in  forceps  delivery.  If  immediate  extrac- 
tion of  the  child  is  not  imperative,  let  the  head  be  held  back  until  the 
parts  are  sufficiently  dilated,  and  gradually  lead  it  out,  the  nucha  being 
made  to  hug  the  subpubic  ligament.  At  the  end  of  the  extraction  of 
the  head,  the  handles  of  the  forceps  will  be  near  to  and  almost  parallel 
with  the  mother's  anterior  abdominal  wall.  Only  one  hand  is  needed 
for  the  forceps,  and  the  other  should  be  used  to  note  the  condition  of  the 
perineum  and  to  protect  it  from  being  torn. 

2.  Occipito-sacral  Position.     After  the  application  of  the  forceps,  the 
pull  must  be  upward  and  somewhat  forward,  increasing  the  head-flexion, 
until  the  occiput  emerges  over  the  anterior  margin  of  the  perineum,  and 
then  the  head  is  delivered  by  extension,  the  nucha  pivoting  upon  the 
anterior  border  of  the  perineum. 

Some  accoucheurs,  among  whom  Charpentier  may  be  mentioned, 
always  attempt  anterior  rotation,  and  it  is  only  when  this  attempt  fails 
that  delivery  over  the  perineum  is  accepted. 

3.  Left  Occipito-anterior  Position.     Supposing  the  head  to  be  in  the 
pelvic  cavity,  the  left  blade,  which  is  introduced  first,  is  passed  to  the 
left  side,  and  posteriorly,  so  that  it  corresponds  with  the  left  sacro-iliac 
joint ;  Very  frequently  the  introduction  of  this  blade  determines  an- 
terior rotation  of  the  occiput,  and  then  the  position  is  simply  occipito- 
pubic,  so  that  the  introduction  of  the  second  blade  is  the  same  as  has 
been  described.     But  when  this  rotation  does  not  occur,  the  right  blade 
is  "  directed  at  first  below,  to  the  right  and  posteriorly,  then  brought  by 
a  very  extensive  spiral1  movement  to  the  level  of  the  right  ilio-pectiueal 
eminence."     After  the  blades  are  applied  and  locked,  traction  with  an- 
terior rotation,  and  delivery  of  the  head  as  in  occipito-pubic  position 
follows ;  no  attempt  at  rotation,  however,  should   be  made  until  the 
head  has  reached  the  pelvic  floor. 

Should  the  head  be  at  the  inlet,  still  the  effort  must  be  made  to  place 
the  blades  at  the  sides  of  the  head.  The  simple  rule  given  by  Pinard 
applies  in  common  to  these,  and  to  all  oblique  or  diagonal  positions 
which  the  head  may  occupy  in  the  pelvis.  Place  the  two  blades  at  the 
two  extremities  of  the  empty  oblique  diameter ;  by  such  diameter  is 
meant  that  in  which  the  transverse  diameters  of  the  head  are,  and 
especially  the  biparietal,  because  this  diameter  does  not  occupy  all  its 
extent,  there  being  always  a  space  left  between  the  former  and  the 
pelvis. 

1  This  is  known  as  the  method  of  Madame  Lachapelle,  and  has  been  described  by  her  as  follows  : 
"  If  the  branches  are  to  be  placed  diagonally,  that  is,  one  behind  on  one  side,  the  other  in  front 
upon  the  opposite  side,  it  will  suffice  to  pass  directly  the  branch  which  ought  to  remain  posteriorly 
over  the  sacro-sciatic  ligament— nothing  arrests  it.  The  other  can  be  easily  managed,  if  I  com- 
mence with  it.  Held  in  the  hand  as  a  pen,  and  leaning  it  across  over  the  opposite  groin,  I  insinu- 
ate the  point  of  the  blade  in  front  of  the  sacro-sciatic  ligament,  then  as  it  enters  further  I  lower 
the  handle,  bringing  it  by  degrees  between  the  thighs,  until  it  inclines  strongly  below.  By  this 
movement  I  have  made  the  end  of  the  blade  describe  a  spiral,  which  the  fingers  in  the  vaeina 
direct  and  complete.  This  movement  carries  the  blade  at  the  same  time  in  front  and  above.  "It  is 
necessary  to  encircle  the  head  by  an  oblique  passage,  which  represents  a  line  extending  from  the 
sacro-iliac  ligament  to  the  horizontal  ramus  of  the  pubes,  and  traced  on  the  interior  of  the  basin. 
The  movement  is  effected  in  the  twinkling  of  an  eye,  without  the  least  pain,  without  the  least 
bruising."  The  spiral  movement  is  not  to  be  employed  in  cases  in  which  the  head  has  not  entered 


THE  FORCEPS.  613 

Winckel  teaches  that  even  if  the  head  is  transverse  in  the  pelvic  inlet 
it  is  necessary  to  apply  the  blades  of  the  forceps  to  the  oblique  diame- 
ter, and  he  regards  it  as  a  mistake  to  apply  one  blade  over  the  brow 
and  the  other  over  the  occiput,  because  the  child  is  thus  easily  injured, 
and  besides  the  antero-posterior  diameter  of  the  head  is  too  large  for 
the  cephalic  curve  and  the  instrument  easily  slips  off. 

Dr.  Fry,  of  Washington,  at  the  meeting  of  the  American  Medical  Association, 
1889,  showed  a  forceps  invented  by  him  for  application  to  the  sides  of  the  head 
when  it  was  transverse  with  reference  to  the  pelvis,  that  is,  in  the  antero-posterior 
diameter  of  the  latter,  and  reported  cases  in  which  he  had  successfully  used  the 
instrument. 

Milne  Murray,1  from  experiments  made  with  the  cephalotribe  upon  the  heads 
of  dead  foetuses,  concluded  that  the  foetal  skull  is  compressible  in  an  antero- 
posterior  direction  by  the  sliding  of  the  occipital  and  frontal  bones  under  the 
parietals;  and  that  the  compression  is  not  accompanied  by  any  appreciable  in- 
crease of  the  transverse  diameters.  Thus  in  a  minor  degree  of  flat  pelvis  in 
which  forceps  delivery  is  indicated,  the  blades  may  be  applied  over  the  ends  of 
the  antero-posterior  diameter. 

4.  Right  Occipito-posterior  Position.  The  introduction  of  the  blades 
is  done  in  the  same  way  as  in  a  left  occipito-anterior  position.  The 
head  is  brought  to  the  pelvic  floor,  then  anterior  rotation2  attempted, 
which,  if  successful,  requires  removal,  and  then  reapplication  of  the 
forceps ;  but  if  the  attempt  should  fail,  the  occiput  must  be  delivered 
over  the  anterior  margin  of  the  perineum. 

5  and  6.  Left  Occipito-posterior  Position  and  Right  Occipito-anterior 
Position.  The  only  difference  in  the  introduction  of  the  blades  is,  that 
in  many  cases  it  is  difficult  to  introduce  the  second,  right  or  posterior 
blade,  after  the  first  or  left  blade  has  been  placed  in  position ;  hence,  if 
this  difficulty  occurs,  the  right  blade  is  introduced  first,  but  of  course 
the  handles  must  be  crossed  before  they  can  be  locked.  The  difficulty 
may  be  obviated  by  following  the  method  of  Stoltz.  After  introducing 
the  right  blade,  raise  the  handle  and  pass  the  left  blade  beneath  it,  and 
then  the  handles  occupy  their  relative  normal  position  without  having 
to  cross  them  after  the  application  of  the  blades. 

Ostermann3  advocates  if  the  head  be  transverse,  or  if  it  be  oblique, 

1  Edinburgh  Obstetrical  Transactions,  vol.  xiii. 

2  It  is  claimed  that  in  natural  labor  anterior  rotation  does  not  occur  until  the  head  has  reached 
the  pelvic  floor.    This  statement  is  too  absolute,  for  the  rotation  may  occur  before  there  is  the  least 
pressure  upon  that  floor.    But  in  artificial  rotation,  as  made  by  the  forceps,  no  effort  should  be 
made  to  this  end  until  the  floor  is  reached  by  the  descending  head.    Traction  should  be  made 
simultaneously  with  the  effort  to  produce  rotation,  and  it  is  important,  too,  that  the  forceps  should 
be  used  to  keep  the  head  well  flexed.    Richardson,  of  Boston,  very  ingeniously  applies  the  forceps 
with  the  anterior  and  posterior  pelvic  curves  reversed,  in  order  to  effect  rotation,  removing  the  in- 
strument as  soon  as  the  desired  change  has  been  accomplished ,  and  then  reapplying  if  necessary 
in  the  normal  position  of  the  blades.    Barnes  holds  that  instrumental  rotation  is  only  exception- 
ally useful,  more  rarely  necessary,  and  is  not  free  from  danger. 

The  chief  objection  that  is  made  to  such  rotation  is  that  if  the  head  be  moved  through  more  than 
one-fourth  of  a  circle,  the  body  being  firmly  held  by  the  contracted  uterus,  and  therefore  not  able 
to  make  a  corresponding  movement,  injury  is  necessarily  done  to  the  spinal  cord.  The  experi- 
ments of  Tarnier  and  Ribemont  have  proved  that  this  opinion  is  erroneous,  for  they  have  demon- 
strated that  the  torsion  of  the  neck  is  distributed  upon  all  the  extent  of  the  cervical  column,  and 
the  first  six  or  seven  dorsal  vertebrse.  Tarnier  states  that  exaggerated  rotation  exposes  the  spinal 
cord  to  injury  less  than  does  the  great  flexion  necessary  to  be  produced  in  order  to  deliver  the  occi- 
put posteriorly. 

Wasseige  states  (Des  Operations  Obstetricales)  that  Van  Huevel  advised  applying  the  new  curva- 
ture of  the  forceps  behind  toward  the  occiput;  as  the  blades  only  enter  the  excavation,  it  is, 
strictly  speaking,  possible,  but,  according  to  Wasseige,  very  difficult  to  execute,  and  he  rejects  it. 
The  method  differs  only  from  that  of  Richardson  in  that  after  rotation  is  effected  there  is  no  re  - 
moval  and  reapplication. 

3  Ueber  combinirte  Zangenextraction.    Zeitschrift  f.  Geburt.  und  Gynakol.    Band.  xxv. 


614  THE  PATHOLOGY  OF  LABOR. 

that  is,  in  an  occi  pi  to-posterior  position,  left  or  right,  anterior  rotation, 
the  forceps  being  applied  to  the  head,  and  an  assistant  acting  by  manip- 
ulation upon  the  shoulders  of  the  child  through  the  abdominal  wall. 
His  success  has  been  the  best  proof  of  the  value  of  this  method.  Ot 
course,  if  the  rotation  has  been  from  a  posterior  position,  the  forceps 
must  be  removed  and  reapplied  before  extraction. 

In  connection  with  Ostermann's  method  of  anterior  rotation  of  the  occiput, 
the  methods  advised  in  two  recent  works  will  be  mentioned,  though  they  should 
have  occupied  a  previous  place.  Grandin  and  Jarman1  say  :  "  With  the  cervix 
fully  dilated  the  hand  is  introduced  into  the  uterus.  If  the  head  has  slightly 
engaged,  it  should  be  gently  pushed  up.  The  foetus  is  now  grasped  and  slowly 
rotated  in  its  long  axis  until  the  occiput  is  anterior.  The  hand  should  be  slowly 
withdrawn  until  the  head  can  be  grasped,  and  in  this  position  the  operator  waits 
for  uterine  contraction.  When  this  has  occurred  the  head  is  driven  down  and 
engagement  ensues.  It  is  wise  to  retain  the  hand  until  two  or  three  contractions 
have  taken  place,  so  that  the  head  may  be  firmly  engaged." 

Herman,2  after  stating  that  the  diagnosis  of  the  position  ought  to  be  made 
by  abdominal  palpation  early,  and  that  anterior  rotation  of  the  occiput  can 
easily  be  accomplished  before  the  rupture  of  the  membranes,  proceeds  as  follows: 
"  Suppose  that  the  child's  belly  looks  forward  and  to  the  left,  its  anterior  shoulder 
will  be  to  the  right  and  in  front.  Standing  by  the  side  of  the  patient,  put  your 
hands  on  the  abdomen,  the  right  hand  behind  the  child's  anterior  shoulder,  the 
left  hand  in  front  of  the  posterior  shoulder.  Then  by  a  repetition  of  gentle 
pushing  movements  push  the  anterior  shoulder  over  toward  the  left  side,  and  the 
posterior  shoulder  toward  the  right  side.  You  will  find  it  quite  easy  to  move 
the  child ;  only,  as  the  pushes  are  given,  not  to  the  child,  but  to  the  uterus,  part 
of  the  effect  is  to  move  the  uterus.  But  a  sufficient  repetition  of  these  move- 
ments will,  unless  the  liquor  amnii  be  unusually  deficient,  or  the  child's  mobility 
for  some  other  reason  be  abnormally  restricted,  bring  the  back  in  front."3 

APPLICATION  OF  THE  FORCEPS  IN  HEAD-LAST  LABORS.  Manual 
delivery  is  to  be  preferred  if  possible.  Winckel  regards  the  forceps  as 
indicated  only  in  those  cases  in  which  the  mouth  cannot  be  reached,  the 
occiput  has  rotated  posteriorly,  and  the  face  remains  stationary  under 
the  symphysis.  Schroder  rejected  the  forceps,  believing  that  if  manual 
traction  could  not  succeed,  it  would  be  impossible  with  the  instrument 
to  extract  a  living  child,  and  that  it  was  dangerous  for  the  mother. 
Budin  regards  the  failure  to  deliver  by  manual  means,  which  is  quite 
exceptional,  as  in  most  cases  due  to  contraction  of  the  os  uteri  about 
the  neck  and  head  of  the  child,  or  to  resistance  of  the  pelvic  floor,  and 
that  under  such  circumstances  the  forceps  should  be  used. 

In  the  application  of  the  instrument,  the  occiput  being  in  front,  the 
child's  body  is  raised,  its  back  toward  the  mother's  abdomen,  and  the 
forceps  blades  applied  to  the  sides  of  the  child's  head  and  extraction 
made,  the  mental  end  of  the  occipito-mental  diameter  coming  out  first. 
But  if  the  occiput  is  posterior,  the  child's  body  is  raised  up,  its  abdo- 
men toward  the  mother's,  the  instrument  applied  as  before,  and  now 
the  occipital  end  of  the  occipito-meutal  diameter  passes  out  first. 

HEAD  MOVABLE  ABOVE  THE  INLET.  In  case  the  forceps  is  applied 
before  the  head  has  entered  the  inlet,  an  application  which  should  be 
avoided  if  possible,  an  assistant  holds  the  head  by  suitable  pressure 

1  Obstetric  Surgery,  1894.  2  Difficult  Labor,  1894. 

3  Before  the  practitioner  is  in  haste  to  adopt  this  treatment,  he  should  remember  that  it  is  only 
in  rare  exceptions  anterior  rotation  does  not  spontaneously  occur. 


THE  FORCEPS. 


615 


upon  the  lower  portion  of  the  mother's  abdomen  during  the  application 
of  the  blades.  Almost  invariably  one  blade  passes  over  one  frontal 
protuberance,  the  other  over  the  side  of  the  occiput  obliquely  opposite ; 
thus,  the  first  blade  over  the  right  side  of  the  frontal  bone,  the  second 
blade  over  the  left  side  of  the  occipital  bone.  If  the  head  cannot  be 
brought  into  the  inlet  after  a  few  vigorous  efforts,  some  other  method 
of  delivery  must  be  resorted  to. 

HEAD  SEPARATED  FROM  THE  TRUNK.  It  may  happen,  by  "  acci- 
dent or  by  design,"  that  the  head  has  been  detached  from  the  trunk  and 
remains  in  the  uterus  after  the  latter  is  delivered.  Removal  by  the 
forceps  is  "  delicate  and  difficult,"  and  should  not  be  resorted  to  unless 
other  means,  such  as  the  use  of  the  hand  and  the  assistance  of  uterine 
contractions,  have  failed.  Make  the  head  fixed,  by  pressure  through 
the  abdominal  wall  or  by  seizing  the  head  with  a  hand  introduced  into 
the  uterus,  and  apply  the  forceps  to  the  sides  of  the  head. 

THE  FORCEPS  IN  FACE  PRESENTATION.  In  presentations  of  the 
face  the  chin  must  rotate  anteriorly  if  the  labor  ends  naturally ;  the 

FIG.  252. 


APPLICATION  OF  FORCEPS  IN  PRESENTATION  OF  THE  FACE. 

chin  in  this  movement  takes  the  place  of  the  occiput  in  vertex  presenta- 
tions. While  anterior  rotation  is  the  rule  in  the  latter,  yet  delivery  is 
still  possible  by  Nature's  unaided  efforts,  even  should  the  occiput  rotate 
posteriorly.  Not  so,  however,  as  to  the  movement  of  the  chin  in  a  face 
presentation,  for  anterior  rotation  is  essential  for  delivery.  It  should, 
therefore,  be  remembered  that,  in  the  application  of  the  forceps,  the  in- 
strument is  valueless  if  such  rotation  cannot  be  effected.  The  difficulty 


616 


THE  PATHOLOGY  OF  LABOR. 


and  the  danger  of  the  forceps  application  to  the  head  above  the  inlet 
lead  obstetricians  to  greatly  prefer  conversion  of  a  facial  into  a  cranial 
presentation,  or  podalic  version.  But  when  descent  into  the  pelvic 
cavity  has  occurred,  and  the  chin  is  right  or  left  anterior,  either  as  a 
primitive  position,  or  as  resulting  from  rotation  from  a  transverse  or  a 
posterior  position,  the  application  of  the  forceps  and  extraction  are  no 
more  difficult  than  in  similar  positions  of  the  occiput.  The  same  rules 
are  followed  as  to  the  introduction  and  articulation  of  the  blades  in  the 
one  case  as  in  the  other ;  but  in  facial  presentations  it  is  especially  im- 
perative that  the  blades  be  upon  the  sides  of  the  child's  head  ;  departure 
from  this  rule,  as,  for  example,  applying  one  of  the  blades  in  the 
trachelo-bregmatic  diameter,  would  give  an  insecure  hold,  and  probably 
do  irreparable  mischief  to  the  child's  throat. 


FIG.  253. 


DELIVERY  BY  THE  FORCEPS  IN  PRESENTATION  OF  THE  FACE. 

After  the  application  of  the  forceps  in  a  mento-anterior  position,  ex- 
tension and  rotation  of  the  chin  into  the  pubic  arch  are  the  movements 
at  first  to  be  executed,  and  then  the  delivery  of  the  head  is  accomplished 
by  flexion;  "care  must  be  taken  in  this  last  step  to  prevent  too  long 
compression  of  the  vessels  of  the  neck  against  the  pubic  joint." 

In  mento-posterior  positions,  either  right  or  left,  the  mode  of  appli- 
cation of  the  forceps-blades  does  not  differ  from  that  employed  in  cor- 
responding occipito-posterior  positions,  and  therefore  need  not  be  re- 
peated. In  transverse  positions,  if  the  forceps  be  used,  the  rule  as  to 
the  application  of  the  blades  to  the  sides  of  the  head  is  necessarily  de- 
parted from,  and  an  oblique  application  is  made  in  which  "  one  blade 
is  placed  upon  the  cheek  and  the  base  of  the  jaw,  while  the  other  is  upon 
the  temporo-occipital  region  of  the  opposite  side." 


THE  FORCEPS.  617 

"  One  ought  not  to  apply  the  forceps  except  in  case  of  absolute  neces- 
sity, in  presentation  of  the  face;  for  an  accouchement  which  may  end 
spontaneously  and  favorably  is  sometimes  arrested  when  its  march  is 
disturbed  by  untimely  attempts;  the  operator  acting  rashly,  if  he  fails 
in  his  attempts,  regrets  too  late  the  resources  which  would  have  been 
found  in  prudent  expectation."  (Tarnier.) 

The  changing  of  a  face  into  a  vertex  presentation  by  means  of  the  forceps  has 
been  recommended.  In  this  proposed  method  the  chin  is  directed  toward  one  of 
the  great  sciatic  foramina,  where,  by  pushing  before  it  the  soft  parts,  it  was 
thought  that  sufficient  room  might  be  obtained  for  the  rotation  of  the  occipito- 
mental  diameter,  so  that  descent  of  the  occipital,  with  ascent  of  the  mental,  end 
might  be  obtained.  This  could  only  succeed  if  the  pelvis  were  large  and  the 
head  small,  so  that  any  attempt  to  accomplish  it  is  but  a  forlorn  hope. 

Dr.  Hodge  thought  that  it  might  occasionally  be  practicable  to  deliver  a  living 
child,  if  the  head  were  small  and  the  perineum  greatly  relaxed,  by  applying  the 
forceps,  when  the  chin  had  rotated  posteriorly,  as  accurately  as  possible  in  the 
direction  of  the  occipito-frontal  diameter,  and  drawing  the  head  down,  then 
causing  the  occipito-mental  diameter  to  revolve  between  the  anterior  margin  of 
the  pernineum  and  the  subpubic  ligament.  Some  cases  are  on  record  in  which 
a  living  child  has  been  delivered  in  a  direct  mento-posterior  position,  either 
spontaneously,  or  after  the  application  of  the  forceps ;  but  they  are  simply  rare 
exceptions  to  a  general  law,  and  the  rule  in  such  positions  is  craniotomy. 

APPLICATION  OF  THE  FORCEPS  IN  PRESENTATION  OF  THE  PELVIS. 
If  the  child  be  dead,  the  blades  may  be  placed  simply  upon  the  sides  of 
its  pelvis,  and  firm  compression  made  without  reference  to  possible  in- 
jury to  the  bones ;  but  if  it  be  living,  there  ought  to  be  interposed  be- 
tween the  handles  of  the  ordinary  forceps,  according  to  Pinard,  some- 
thing that  will  prevent  their  coming  too  close  together,  and  thus  avoiding 
injurious  compression.  Pinard  directs  the  blades  to  be  applied  as  far 
as  possible,  so  that  the  pelvis  may  be  seized  by  its  bisiliac,  or  bistro- 
chanteric  diameter ;  nevertheless,  he  states  that  he  has  seen  Tarnier 
with  his  forceps  seize  the  pelvis  by  the  sacropubic  diameter,  the  genital 
organs  being  in  the  fenestra  of  one  of  the  blades,  and  extract  an  infant 
without  causing  any  lesion.  The  blades  ought  not  to  pass  the  iliac 
crests,  lest  injury  be  done  the  abdomen.  The  extraction  must  be  made 
slowly. 

ACCIDENTS  AND  DANGERS  IN  THE  USE  OF  FORCEPS.  The  blades 
may  slip,  the  liability  to  this  accident  being  greater  if  the  head  is  high  ; 
slipping  usually  occurs  because  the  blades  have  been  improperly  applied, 
or  because  the  pulling  is  in  the  wrong  direction.  Madame  Lachapelle 
describes  two  varieties  of  this  accident,  vertical  and  horizontal.  The 
first  may  occur  when  the  head  is  high,  so  that  it  recedes  during  the  ap- 
plication of  the  blades,  and  hence  is  incompletely  and  thus  insecurely 
grasped ;  or  it  may  happen  that  the  operator,  misled  by  a  large  caput 
succedaneum,  does  not  introduce  the  blades  far  enough  ;  the  handles  do 
not  readily  approximate,  or  their  points  embrace  one  of  the  transverse 
diameters  of  the  head.  So,  too,  the  accident  may  happen  from  the 
head  being  so  small,  or  having  so  little  firmness  that  the  forceps  cannot 
hold  it.  Horizontal  slipping  occurs  when  the  blades  imperfectly  seize 
the  head,  being  too  far  to  its  anterior  or  to  its  posterior  surface,  and  it  is 
held  only  by  the  posterior  or  by  the  anterior  pelvic  curvature  of  the  in- 
strument ;  this  condition  may  be  recognized  by  the  easy  approximation 


618  THE  PATHOLOGY  OF  LABOR. 

of  the  handles.  The  consequences  of  the  slipping,  when  vigorous  trac- 
tion is  made,  are  the  sudden  escape  of  the  instrument  from  the  pelvis, 
with  more  or  less  injury  to  the  mother's  soft  parts  and  to  the  child,  and 
the  operator  may  find  himself  prostrate  on  his  back.  The  obstetrician 
guards  against  this  accident  by  observing  whether  the  part  of  the  fetal 
head  nearest  the  lock  is  receding,  the  beginning  of  the  blades  becoming 
visible  without  the  handles  taking  the  usual  direction,  and  the  blades 
appearing  empty,  while  the  forceps  is  "getting  longer."  The  moment 
any  indication  that  the  blades  are  slipping  occurs  all  traction  should 
cease,  the  instrument  be  unlocked,  and  the  blades  passed  further  in. 

It  has  sometimes  happened  that  one  of  the  blades  is  pulled  straight, 
the  head  curve  being  quite  lost.  Elliot  describes  this  as  having  oc- 
curred with  him  in  using  a  Simpson  forceps ;  and  I  know  of  a  recent 
case  in  which  this  accident  happened  with  a  Hodge  forceps,  the  de- 
livery of  the  child  being  very  readily  effected  afterward  by  the  use  of 
McFerran's  axis-traction  forceps.  It  is  probable  that  the  accident  oc- 
curs from  a  want  of  proper  direction  of  the  traction,  or  from  too  great 
effort  to  force  a  delivery  before  the  head  is  sufficiently  moulded. 

INJURIES  TO  THE  MOTHER  BY  FORCEPS.  Among  the  dangers  of 
the  forceps  to  the  mother  are  prolapse  of  the  uterus  or  lacerations  of 
the  cervix ;  if  great  traction  is  made  before  the  dilatation  of  the  os,  the 
lower  uterine  segment  may  be  dragged  down,  torn,  or  seriously  bruised  ; 
the  vaginal  vault  may  be  penetrated  by  the  forceps-blade,  or  the  vagina 
may  be  torn  elsewhere.  Spiegelberg  mentions  an  instance  he  knew,  in 
which  the  anterior  vaginal  wall  was  torn  from  the  fornix  down  to  the 
lowest  portion  of  the  urethra.  u  Severe  compression  of  organs  contained 
in  the  pelvis  may  lead  to  inflammation  ending  in  suppuration  or  gan- 
grene, causing  fistulae,  abscesses  and  partial  paralyses  ;"  injuries  of  the 
external  generative  organs  and  laceration  of  the  perineum ;  fractures  of 
the  pelvis  or  separation  of  pelvic  joints ;  finally,  a  rapid  forceps  de- 
livery may,  if  suitable  care  be  not  taken,  lead  to  post-partum  hemor- 
rhage. 

INJURIES  TO  THE  CHILD  BY  FORCEPS.  The  minor  ones  are 
abrasions,  bruises,  or  even  cutting  the  scalp,  the  cutting  sometimes 
reaching  the  subjacent  bone.  Depressions  and  even  fissures  of  the 
bones  may  be  produced.  Injuries  to  the  brain  have  been  reported, 
immediately  fatal  results  sometimes  ensuing,  while  at  other  times  remote 
evil  has  been  ascribed  to  the  instrument.  Winkler  and  Ballaan1  at- 
tributed the  idiocy  of  two  subjects  of  whom  they  made  autopsies  to 
cerebral  atrophy  caused  by  pressure  of  the  forceps  at  birth.  Ahlfeld 
regards  it,  while  not  proved,  as  not  improbable,  that  children  delivered 
by  the  forceps,  in  later  life  are  more  liable  to  psychical  diseases  and 
epilepsy.  Dr.  Horatio  C.  Wood  has  said  :2  "  The  brain  at  birth  is  so 
soft,  so  liable  to  injury  that  while  I  would  not  have  the  obstetrician 
entirely  discard  the  use  of  the  forceps,  I  think  he  should  never  take 
the  instrument  in  his  hand  without  bearing  in  mind  the  possibility  of 
doing  serious  permanent  injury  to  the  nerve  centres  of  the  child." 

1  Centralblatt  f.  Gynakol.,  1889- 

2  From  remarks  made  in  the  discussion  of  author's  paper  upon  Injuries  to  the  Fo3tus  During 
Labor,  read  before  the  Philadelphia  County  Medical  Society.    Medical  and  Surgical  Reporter,1887. 


THE  FORCEPS.  t>19 

Charpentier  states  that  he  has  seen,  as  a  consequence  of  an  application  of  the 
forceps  by  an  inexperienced  operator,  one  of  the  branches  pushed  with  such 
violence  that  the  blade  penetrated  the  scalp  near  the  occiput,  passing  as  far  as 
the  root  of  the  nose,  detaching  in  its  progress  the  skin  from  the  cranium  ;  the 
child  died  at  the  end  of  forty-eight  hours.  I  have  observed  a  similar  case  ;  the 
operator  had  passed  one  blade  on  the  outside  of  the  scalp,  but  the  other  was 
applied  beneath  the  scalp,  when  the  difficulty  in  making  it  penetrate  far  enough 
led  him  to  ask  professional  assistance ;  fortunately,  the  child  was  dead. 

Intra-cranial  effusion  of  blood  may  occur,  oftener,  as  suggested  by 
Spiegelberg,  not  from  the  direct  compression  of  the  forceps,  but  indi- 
rectly from  drawing  the  head  rapidly  through  the  narrow  birth-canal. 
Paralysis  of  the  facial  nerve,  usually  on  one  side  only,  in  rare  cases  ou 
each  side,  may  occur  from  direct  pressure  by  the  forceps-blade  upon 
the  nerve-trunk ;  the  compression  may  be  of  one  of  the  branches  only, 
and  then  the  paralysis  is  only  of  the  parts  supplied  by  it.  Generally 
this  paralysis  disappears  in  one  or  two  weeks  without  treatment,  but  in 
some  instances  it  lasts  for  years,  and  then  may  be  regarded  as  incurable. 
So,  too,  the  brachial  plexus  may  be  injured  by  the  point  of  one  of  the 
blades,  and  paralysis  of  the  parts  supplied  by  it  result. 

I  have  seen  a  case  in  which  forceps  extraction  was  made,  one  of  the 
blades  being  applied  partly  over  the  frontal  bone,  and  exophthalmus 
resulted  ;  the  child  was  dead,  and  the  mother  perished  a  few  days  after 
of  septic  infection. 

Pincus1  attributes  some  cases  of  injury  to  the  sterno-cleido-mastoid 
muscle  to  improperly  constructed  forceps  and  to  torsion.  The  last  fact 
should  be  borne  in  mind  before  attempting  to  compel  anterior  rotation 
in  an  occipito-posterior  position. 

While  the  obstetrician  will  neither  resort  to  the  forceps  "  from  com- 
plaisance, nor  reject  it  from  cowardice,"  he  must  be  quite  sure  that  the 
interests  of  the  mother  or  of  the  child,  or  both,  demand  the  use  of  the 
instrument,  and  that  the  conditions  are  present  rendering  that  use  safe. 

THE  VECTIS.  This  instrument  is  supposed  to  be,  like  the  forceps, 
the  invention  of  Chamberlen.  The  instrument  has  been  given  different 

FIG.  254. 


forms,  according  as  it  was  used  chiefly  or  exclusively  as  a  lever  or  as  a 
tractor;  thus  Roonhuysen's  instrument  was  a  plate  of  steel,  slightly 
curved,  but  the  form  preferred  by  the  few  obstetricians  who  use  the 
instrument  is  that  of  a  fenestrated,  curved  blade,  with  a  straight  handle  ; 
Spiegelberg  has  briefly  referred  to  it  as  being  one  blade  of  the  forceps, 
and  therefore  an  unnecessary  instrument.  Lowder's  instrument,  of 
which  an  illustration  is  given,  is  probably  the  best.  It  has  been  used 
chiefly  to  increase  flexion  and  to  assist  rotation,  but  is  rarely  employed 
and  by  but  few  obstetricians  at  the  present  day. 

1  Zeits.  fur  Geburt.  und  Gynak.,  1895. 


CHAPTER    XII. 

MANUAL   KEMOVAL   OF   THE   PLACENTA — SYMPHYSEOTOMY. 

MANUAL  KEMOVAL  OF  THE  PLACENTA.  If  the  placenta  is  not 
spontaneously  expelled  within  two  hours  after  the  birth  of  the  child,  and 
if  by  stimulating  uterine  contractions,  by  manipulation  through  the 
abdominal  wall,  assisted  by  moderate  traction  on  the  cord,  it  is  still 
retained,  its  removal  by  the  hand  is  usually  indicated.  In  order  to 
guide  the  hand  that  is  to  enter  the  uterus  into  the  os,  and  also  to  the 
position  of  the  placenta,  the  other  hand  pulls  on  the  cord,  so  that  it  is 
made  moderately  tense.  The  hand,  after  proper  preparation — washing 
and  antiseptics — is  passed  in  a  cone-shape,  the  fingers  and  thumb 
brought  together  so  that  the  cone  is  formed,  into  the  vagina,  thence 
into  the  uterus  and  the  placenta  found,  and  then  the  other  hand,  no 
longer  required  to  pull  upon  the  cord,  is  placed  upon  the  abdominal 
wall,  so.  that  the  uterus  is  grasped  by  it.  The  placenta  is  detached, 
partially  detached,  or  completely  adherent.  In  the  first  case  the 
operator  includes  as  much  as  he  can  of  it  in  his  half-folded  hand,  not 
instantly  withdrawing  placenta  and  hand,  but  rather  invites  by  the 
irritation  of  the  hand  within  and  by  friction  and  compression  of  the 
hand  without,  uterine  contraction  which  tends  to  expel  both  hand  and 
placenta.  In  the  second  case,  that  is,  in  partial  detachment  of  the 
placenta,  there  is  no  hemorrhage  if  the  womb  be  well  contracted ;  but 
even  if  there  be  no  bleeding,  still  more  if  there  is,  the  placenta  is  to  be 
completely  detached,  this  separation  being  effected  by  continuing  the 
separation  from  the  part  where  it  has  begun  ;  in  this  manipulation, 
supposing  the  right  hand  to  be  in  the  uterus  and  the  placenta  to  be  sit- 
uated upon  the  posterior  wall  of  the  uterus,  the  ulnar  border  of  the 
hand  is  used  with  a  sort  of  sawing  motion,  or  like  the  continuous  move- 
ments made  in  using  a  paper-cutter,  the  back  of  the  hand  being  toward 
the  uterine  wall,  and  the  external  hand  keeping  the  uterus  in  position, 
and  assisting  in  defining  the  uterine  wall  so  that  the  internal  fingers  do 
it  no  damage.  If  the  placenta  be  situated  upon  the  anterior  wall,  then 
the  radial  margin  furnishes  the  edge  of  the  paper-cutter;  but  if  the 
attachment  be  to  the  fundus,  the  ends  of  the  fingers  must  make  the 
separation,  being  careful  that  they  turn  toward  the  soft  placenta  rather 
than  toward  the  harder  uterine  wall,  and  thus  harm  to  the  latter  is 
avoided.  Of  course,  all  manipulations  must  cease  during  a  uterine 
contraction.  If  the  placenta  be  completely  adherent,  the  method  of 
removal  does  not  differ,  but  is  more  difficult.  It  ought  to  be  added  that 
an  adherent  placenta  is  very  rare ;  that  is,  pathological  adhesion,  in 
consequence  possibly  of  endometritis,  is  very  seldom  in  occurrence. 
Hildebrandt  advised  separation  within  the  foetal  membranes,  these  being 
made  to  form  a  glove-like  covering  for  the  operating  hand,  on  the 


SYMPHYSEOTOMY.  621 

ground  that  thus  avoidance  of  injury  to  the  uterine  wall  was  secured, 
and  also  danger  of  septic  infection  avoided.  Spiegel  berg  found  the 
method  successful  only  in  case  the  attachment  was  not  strong,  and  that 
the  assistance  derived  from  tactile  sensations  was  greatly  diminished 
by  this  method.  Budin  advises,  if  the  hand  has  entered  the  foetal  sac, 
to  tear  the  membranes  at  the  border  of  the  placenta,  so  as  to  begin  the 
separation  there ;  if  this  fails,  then  the  placenta  is  penetrated  near  its 
centre,  and  the  fingers  introduced  into  the  button-hole  thus  formed,  and 
the  separation  made  with  them,  making  a  circle  from  this  starting-point 
between  the  placenta  and  uterus.  In  case  hour-glass  contraction  is 
present,  or  a  similar  contraction  at  one  of  the  uterine  cornua  holds  the 
placenta  imprisoned,  it  may  be  the  stricture  can  be  overcome  by  a 
hypodermatic  of  morphine  and  chloroform  inhalation,  then  dilatation 
with  one,  two,  three,  four  fingers,  until  finally  the  hand  enters,  or  dila- 
tation with  Barnes's  hydrostatic  dilators  may  be  successful.  If  these 
means  fail,  Budin's  answer  is  antisepsis  and  patience.  Certainly  the 
condition  of  the  woman  is  one  of  imminent  peril  ;  but  by  the  use  of 
antiseptic  washes  and  suppositories  we  can  materially  lessen  that  peril, 
and,  in  many  instances,  the  patient  waiting  is  followed  by  the  spon- 
taneous detachment  and  expulsion  of  the  placenta. 

Chazan,1  who,  in  correspondence  with  the  views  of  obstetricians  generally, 
regards  placental  retention  as  in  almost  all  cases  failure  of  placental  detachment, 
this  failure  not  indicating  abnormal  adhesion — has  for  many  years  abandoned 
the  usual  treatment,  stating  that  he  has  been  quite  successful  pursuing  another 
plan.  A  firm  and  continued  pull  upon  that  part  of  the  placenta  which  has 
been  detached — usually  there  is  such  a  part — will  cause  the  detachment  of  the 
entire  afterbirth.  In  most  cases  it  is  not  necessary  to  pass  even  the  fingers 
into  the  uterine  cavity,  for  the  separated  portion  will  be  found  in  the  cervical 
canal,  sometimes  indeed  in  the  vagina.  Exceptionally  this  portion  is  central 
instead  of  marginal,  and  then  the  finger  bores  through  that  part  of  the  placenta, 
and  using  it  as  a  hook  detaches  the  rest  of  the  placenta  by  pulling  on  it. 

SYMPHYSEOTOMY.2  By  this  is  meant  section  of  the  pubic  joint  to 
facilitate  or  render  possible  the  birth  of  a  living  child  in  stenosis  of  the 
pelvis. 

HISTORICAL.  Pare13  stated  he  had  heard  it  said  that  in  Italy  the  pubic 
bones  were  broken  in  young  girls  for  the  purpose  of  facilitating  labor.  It  cer- 
tainly was  a  strange  rumor  to  be  credited  by  the  great  French  surgeon.  Dela- 
courvee,  a  French  physician  living  at  Warsaw,  in  the  year  1655  divided  the 
symphysis  in  a  woman  who  died  after  four  days'  labor  undelivered,  and  thus 
permitted  the  child,  whose  head  Lad  been  wedged  in  a  narrow  pelvis,  to  be 
extracted.  A  similar  operation  was  done  by  Plenck,  in  Hungary,  in  1766.  A 
French  medical  student — J.  E.  Sigault — made  the  subject  of  his  inaugural  thesis, 
1773,  a  discussion  of  the  question,  whether  in  labor  contra  naturam,  section  of 
the  pubic  bones  would  not  be  more  prompt  and  safer  than  the  Caesarean  opera- 
tion. Sigault  was  led  to  the  advocacy  of  syraphyseotomy  by  a  memoir  read  by 
Louis  before  the  Academy  of  Surgery,  upon  the  separation  of  the  bones  of  the 
pelvis.  In  1777  Sigault4  performed  his  first  operation  on  a  woman  who  was  the 

1  Ueber  Placenta  retention  nach  rechtzei tiger  Geburt.,  1894. 

2  In  employing  this  word  I  have  complied,  so  far  as  the  use  of  e  is  concerned,  with  the  com- 
mon usage  of  recent  French  and  English  writers.    Nevertheless,  Kossmann,  Pathologic  unserer 
Kuntsausdriiche,  Monatsschrift  f.  Geburtshiilfe  und  Gynakologie,  June,  1895,  refers  to  it  as  a  hor- 
rible word,  and,  probably,  were  we  to  use  an  accurate  designation  we  would  choose  Symphysitome. 

3  For  several  of  the  facts  here  given  I  am  indebted  to  Gotchaux's  Monograph,  De  la  Symphy- 
seotomie,  Paris,  1893. 

4  Most  authorities  state  that  this  was  the  first  symphyseotomy  upon  the  living  subject;  but  Kal- 
tenbach  says  that  the  operation  was  done  in  Naples  in  1774,  by  Domenico  Ferrara. 


622  THE  PA  THOL  OGY  OF  LAS  OR. 

wife  of  a  soldier,  and  who  had  been  pregnant  four  times  previously,  the  children 
being  dead.  Child  and  mother  were  saved,  but  the  latter  suffered  many  years 
with  a  vesico-vaginal  fistula.  Four  other  operations  were  done  by  him,  all  of 
the  children  perishing,  and  in  the  last  the  mother  also.  From  his  first  operation 
until  1800,  that  is,  a  period  of  twenty-three  years,  the  operation  was  done  thirty- 
four  times,  nineteen  of  these  being  in  France. 

The  mortality  of  the  operation  was  very  great,  and  obstetric  authorities  were  al- 
most unanimous  in  condemning  it.  Nevertheless,  though  rejected  in  the  country 
where  it  had  its  birth,  symphyseotomy  found  occasional  advocates  in  Italy  during 
the  first  half  of  the  present  century  ;  it  is  especially  to  the  Naples  school  that  the 
profession  ia  indebted  for  the  preservation  and  improvement  of  the  operation. 
Of  that  school,  no  one  has  done  so  much  to  establish  the  value  of  symphyseotomy 
as  Morisani,  whose  first  operation  was  done  in  1879.  The  next  most  prominent 
Italian  name  connected  with  the  revival  of  the  operation  is  that  of  Mangiagalli, 
of  Milan.  The  operation  has  been  received  with  much  favor  in  France,  and, 
owing  chiefly  to  the  careful  researches  and  contributions  of  Dr.  Robert  P.  Harris, 
also  in  this  country ;  many  prominent  German  authorities  accept  it,  but  in 
England  its  progress  has  been  slow. 

Morisani,  at  the  International  Congress,  in  Rome,  1894,  asserted  that 
by  symphyseotomy  a  well-developed  foetus  at  term  can  pass  through  a 
pelvis  narrowed  between  the  limits  of  67  to  88  millimetres.  These  ad- 
ditional statements  were  made  by  him.  As  a  rule,  the  operation  should 
be  done  at  term,  after  labor  has  begun  and  dilatation  advanced.  It  is 
not  a  good  operation  if  the  foetus  is  dead  or  seriously  compromised  ; 
nor  is  it  to  be  done  in  connection  with  induced  labor  ;  the  forceps  may 
be  used,  but  it  is  not  indispensable ;  finally,  in  some  cases  it  may  be 
done  in  connection  with  embryotomy  if  the  foetus  is  dead. 

So  far  for  the  position  assigned  symphyseotomy  by  its  chief  living  promoter. 
All  do  not  accept  the  teaching  of  Morisani.  Sanger,  for  example,  with  twelve 
Csesarean  sections  and  no  death,  believes  symphyseotomy  should  be  more  re- 
stricted, and  greater  extension  given  the  former  operation.  Leopold  would,  if 
possible,  avoid  it  in  primiparse;  and  in  multipart,  if  the  conjugate  is  only  seven 
centimetres,  induce  premature  labor ;  if  too  late,  no  interference  at  first,  and  if 
the  labor  does  not  terminate  naturally,  version  for  it  is  possible  in  the  flat  pelvis 
with  a  true  conjugate  of  seven  centimetres,  and  in  a  generally  contracted  pelvis, 
the  conjugate  being  seven  and  one-half  centimetres,  to  deliver  a  child  of  mean 
volume  at  term. 

Of  course,  the  extravagant  claim  for  Walcher's1  position,  that  by  it  in  many 
cases  symphyseotomy  will  be  superseded,  can  find  but  little  acceptance. 

Ahlfeld  regards  determining  the  indications  as  quite  complex,  and  only  pos- 
sible for  the  most  skilled  obstetrician.  He  further  believes  that  the  operation 
has  been  in  late  years  often  done  unnecessarily  and  for  the  love  of  operating. 
He  also  states  that  the  next  years  must  teach  us  how  many  women  are  injured 
by  the  operation,  and  remain  injured,  and  also  as  to  the  result  in  private,  com- 
pared with  hospital  practice. 

In  conversation  with  Professor  Olshausen  last  summer  he  expressed  the 
opinion  that  the  operation  was  one  for  the  hospital. 

Among  the  dangers  of  the  operation  are  severe  hemorrhage,  tears  of 
the  urethra,  bladder,  or  vagina  ;  septic  infection,  inflammation  of  the 
joint  may  follow,  or  there  may  be  a  failure  of  firm  union.  Yet,  it  is  to 
be  remembered  that  such  results  are  exceptional,  and  can  usually  be 
averted. 

MORTALITY.    Neugebauer's  statistics,  from  1887  to  the  end  of  1893, 

1  Those  who  will  read  Varnier's  criticism  of  the  claim,  Annalesde  Gynecologic,  December,  1894, 
will  accord  small  importance  to  Walcher's  position. 


SYMPHYSEOTOMT.  623 

include  278  operations,  and  there  were  31  deaths.  Several  died  from 
pneumonia,  two  from  hemorrhage,  and  in  a  patient  of  Chrobak's  the 
record  is  "  purulent  endometritis,  rupture  of  the  urethra,  of  the  vagina, 
and  of  the  neck  of  the  uterus,  septicsernia,  amemia,  and  rupture  of  both 
sacro-iliac  joints."1  Nevertheless,  the  majority  of  deaths  were  from 
septic  infection. 

Harris2  states  that  the  operation  has  been  done  in  the  United  States, 
in  fifteen  years,  74  times;  10  women  and  18  children  perishing. 
Uniting  the  American  cases  with  those  of  Neugebauer  for  1892  aud 
1893,  he  finds  the  percentage  of  maternal  deaths  over  11  ;  that  of 
symphyseotomies  in  Canada  and  the  United  States  he  states  is  more 
than  12. 

OPERATION.  There  are  different  methods  of  operating,  but  the  chief 
ones,  those  generally  employed,  are  that  of  Morisani,  and  that  of  Pinard, 
and  these  only  will  be  described. 

Morisani  has  the  patient  lying  at  the  edge  of  the  bed,  in  the  position 
for  obstetric  operations,  while  the  operator  is  directly  in  front ;  she  is 
anesthetized.  Having  shaved  and  carefully  disinfected  the  genital 
parts  and  the  hypogastrium,  a  metallic  female  catheter  is  introduced 
into  the  bladder;  then  an  incision  is  made  two  to  three  centimetres  long 
vertically  just  above  the  symphysis  ;  the  retro-pubic  tissues  are  detached 
after  the  incision  has  penetrated  to  the  superior  border  of  the  articula- 
tion ;  in  this  separation  of  the  tissues,  the  operator  keeps  his  finger  close 
to  the  posterior  surface  of  the  symphysis.  By  the  way  thus  made  Gal- 
biati's  sickel-shaped  knife,  a  strong  bistoury,  probe-pointed  and  curved 
upon  the  cutting-edge,  is  introduced.  The  knob  is  passed  below  the 
inferior  border  of  the  articulation,  upon  which  the  cutting  curve  of 
the  instrument  is  now  brought ;  then,  by  movements  of  the  wrist,  the 
joint  is  divided  from  below  above,  and  from  behind  in  front.  He 
further  states  that  he  has  sometimes,  instead  of  Galbiati's  knife,  used  a 
probe-pointed  bistoury,  with  a  short,  firm  blade,  and  opened  the  joint 
from  before  backward. 

Pinard  makes  an  incision  eight  to  ten  centimetres  long,  its  lower  end 
being  above  the  clitoris,  and  slightly  deviating  in  order  to  spare  this 
organ  and  its  vessels.  Next  the  recti  muscles  are  separated  at  the  supe- 
rior part  of  the  wound,  in  order  to  permit  the  finger  to  enter  into  the 
pre-vesical  cavity  to  protect  the  bladder  and  to  feel  the  projection  of 
the  joint.  "Then  having  a  clear  conception  of  the  median  line  I  cut 
the  symphysis  from  above  belo'w,  and  from  in  front  behind,  by  suc- 
cessive strokes  of  the  bistoury,  reserving  the  sub-pubic  ligament  until 
the  last." 

Arterial  hemorrhage  is  met  by  ligature  or  torsion  of  vessels,  and 
venous  bleeding  by  tampon  of  sterilized  gauze. 

The  separation  of  the  pubic  bones  will  be  6  to  8  centimeters,  or  two 
or  three  inches ;  too  wide  a  separation  is  prevented  by  assistants  press- 
ing the  trochauters  inward,  lest  serious  injury  be  done  the  sacro-iliac 
joints. 

1  Jahresbericht  iiber  die  Fortschrift  auf  dem  Gebiete  der  Geburtshiilfe  und  Gyniikologie,  i.  for 
the  year  1893. 
-  The  American  Gynecological  and  Obstetrical  Journal,  June,  1895. 


624  THE  PATHOLOGY  OF  LABOR. 

If  labor  paius  are  active,  delivery  may  be  left  to  Nature;  in  the 
majority  of  cases,  however,  either  version  or  the  forceps  has  been  em- 
ployed. After  labor  is  over  the  parts  are  thoroughly  cleansed,  and  an 
antiseptic  employed ;  then  the  divided  parts  are  pressed  together,  and 
stitches  of  silk  or  of  silkworm-gut  unite  the  superficial  incision,  some, 
indeed,  use  silver-wire  sutures  to  join  the  pubic  bones,  and  an  antiseptic 
dressing  is  applied  ;  a  firm  bandage  or  adhesive  straps  are  employed  to 
keep  the  divided  parts  in  contact.  Plaster-of-Paris  bandage,  Martin's 
rubber  bandage,  or  Esmarch's,  and  two  bags  of  sand  placed  one  on  each 
side  of  the  patient,  are  among  the  many  means  that  have  been  employed 
to  secure  immobility  of  the  separated  bones. 

The  dorsal  position  is  kept  during  the  first  week,  and  after  that  the 
patient  may  be  changed  to  either  side,  when  she  desires  it.  In  favor- 
able cases  the  joint  is  so  well  united  in  three  weeks  that  she  may  be 
permitted  to  sit  up,  and  after  a  few  days  may  walk. 

FAEABEUF'S  OPERATION,  OR  ISCHIO  PUBIOTOMY.  In  an  instance 
of  a  pregnant  woman  having  an  oblique-oval  pelvis,  Naegele's  pelvis,  by 
the  advice  of  Farabeuf  Pinard  performed  ischio-pubiotomy — the  bones 
of  the  anchylosed  sides  were  divided— and  a  living  child  was  born,  the 
mother  perfectly  recovered.  This  operation  was  done  in  1892. 


CHAPTER    XIII. 

THE   (LESAREAN    OPERATION    AND    ITS    SUBSTITUTES. 

BY  the  Caesarean  section  or  operation  is  meant  opening  the  abdomen 
and  the  uterus,  and  extracting  the  foetus  through  the  incision. 

The  operation  performed  after  death  is  a  very  ancient  one,  having  been  estab- 
lished by  the  Romans  as  a  law  centuries  before  the  Christian  era,  its  purpose 
being  to  secure  citizens  to  the  State.  The  Christian  Church  strongly  enjoined 
the  operation,  even  when  the  mother's  death  occurred  quite  early  in  pregnancy. 
The  first  known  operation  upon  the  living  subject  was  by  Jacob  Nuffer,  a  sow- 
gelder,  in  1500,  the  patient  being  his  wife ;  she  recovered,  and  afterward  bore 
several  living  children.  Kleinwiichter  states  that  the  next  operations  were  by 
Doring,  1531, .and  by  Donat  in  1549,  and  that  the  first  operation  in  Germany 
was  by  Trautmann,  in  Wittenberg,  in  the  year  1610. 

TERMS  DESIGNATING  THE  C^SAREAN  OPERATION  AND  ITS  SUB- 
STITUTES. The  term  laparotomy2  has  been  strangely  perverted  from 
its  etymological  and  original  meaning,  and  applied  as  part  of  a  compound 
word  to  the  Csesarean  operation,  to  that  of  Porro,  and  to  that  known 
by  the  name  of  Thomas.  It  will  be  better,  while  protesting  against 
this  great  perversion,  to  replace  the  various  compounds  of  laparotomy 
by  correct  terms,  and  thus  the  Csesarean  operation  will  be  called  gastro- 
hysterotomy ;  gastro-hysterectomy  is  the  proper  designation  for  Porro's 
operation,  and  gastro-elytrotomy,  the  name  used  by  JBaudelocque,  is  the 
appropriate  one  for  the  operation  commonly  called  laparo-elytrotomy.3 

INDICATIONS  FOR  GASTRO-HYSTEROTOMY.  These  are  absolute  and 
relative.  When  there  is  such  obstruction  of  the  birth-canal,  whether 
arising  from  uterine  tumors  or  tumors  of  adjacent  organs,  or  of  the 
pelvis,  or  from  conditions  of  the  cervix  or  of  the  vagina,  or  from  pelvic 
contraction,  that  even  a  mutilated  fetus  cannot  be  delivered  through  the 
natural  passage — the  operation  should  be  done. 

In  regard  to  pelvic  contraction  as  furnishing  an  absolute  indication 
for  gastro-hysterotomy,  we  may  accept  the  limits  assigned  by  Winckel, 

1  The  earliest  history  of  this  operation  which  I  have  had  the  opportunity  of  reading  is  given  by 
Scultetus  in  his  Armamentarium  Chirurgicum,  Frankfort,  1666.    We  have  the  picture  of  a  woman 
at  the  end  of  her  first  pregnancy  some  days  in  labor  without  relief  from  Nature's  efforts,  or  from 
the  assistance  of  "  thirteen  midwives  and  several  lithotomists."    The  husband,  despairing  of 
help  from  these  means,  suggests  others  to  his  wife,  and  she  consents.    Next  he  procured  a  license 
from  the  civil  authority,  and  returning  home,  first  addresses  the  midwives,  exhorting  them  to  be 
brave,  but  advising  the  timid  to  retire,  and,  as  a  consequence,  eleven  withdrew,  only  two  remain- 
ing to  assist  him  ;  the  lithotomists  also  remained.    He  places  his  wife  upon  the  table,  implores 
Divine  help,  and  then  incises  the  abdomen  non  secus  ac  alicui  porco.    Almost  immediately  after 
the  incision  had  been  made  a  living  child  was  extracted  uninjured,  and  the  woman  made  a  rapid 
recovery. 

2  Laparotomie  (from  /Mtrapa,  flank,  and  TO//?},  section).    Operation  for  lumbar  hernia  or  for 
artificial  anus,  practised  in  the  lumbar  regions.    Litre  and  Robin's  Dictionary  of  Medicine,  Sur- 
gery, etc- 

3  Cosliotpmy  has  been  proposed  by  Dr.  R.  P.  Harris  as  an  appropriate  term  for  abdominal  sec- 
tion, and  it  has  been  generally  accepted  by  the  profession  in  this  country  and  by  many  abroad. 
Medical  language  so  abounds  with  neologisms,  that  a  new  word,  though  correct  and  appropriate, 
should  not  be  introduced  unless  absolutely  necessary.    It  has  been  stated  that  the  Arabic  has  a 
thousand  names  for  a  lion,  but  in  science  a  synonyme,  or  an  alias  is  seldom  advisable. 

40 


626  THE  PATHOLOGY  OF  LABOR. 

and  which  have  been  quoted  on  a  previous  page,  2.6  inches  conjugate 
in  a  generally  contracted  pelvis,  and  2.1  inches  in  a  flat  pelvis.  Yet 
embryotomy  in  pelves  that  approximate  such  narrowing  will,  in  the 
hands  of  those  who  are  not  expert  and  possessed  of  the  necessary  facil- 
ities for  operating,  often  if  not  usually  prove  more  difficult  and  more 
tedious  than  abdomino-uterine  section,  or  exsection.  Nevertheless  let 
these  limits  be  recognized. 

The  relative  indication  is  given  by  those  pelves  so  contracted  that  a 
living  child  cannot  be  delivered  at  term,  or  by  the  induction  of  pre- 
mature labor,  or  if  the  pregnancy  has  advanced  beyond  the  time  for  the 
safe  induction  of  labor.  This  question  will  be  further  considered  under 
the  head  of  embryotomy. 

TIME  OF,  PREPARATION  OF  PATIENT  FOR,  AND  MODE  OF  OPER- 
ATING. If  a  choice  of  time  can  be  made,  it  is  preferable  to  do  the 
operation  about  the  end  of  pregnancy,  but  before  labor  begins.  The 
patient  is  given  a  bath  the  evening  before,  soap  being  used  with  the 
water,  and  the  skin  thoroughly  cleansed.  The  bowels  are  moved  freely 
in  the  morning  of  the  day  on  which  the  operation  is  done,  the  vagina 
thoroughly  cleansed  by  an  antiseptic  injection,  and  immediately  before 
operating  a  catheter  is  introduced  so  that  it  is  certain  the  bladder  is 
empty.  The  sub-umbilical  region  is  shaved,  the  part  washed  with  soap 
and  water,  then  with  ether  or  antiseptic  solution.  The  lower  limbs  are 
each  wrapped  with  a  blanket  or  shawl,  and  the  chest  properly  protected 
from  cold.  The  operator  has  ready  a  bistoury,  several  haemostatic  forceps, 
sponges  or  antiseptic  gauze,  scissors,  needles,  needle- holder,  silk  of  two 
sizes,  rubber  tubing — for  encircling  the  neck  of  the  uterus,  if  he  prefers 
this  method  of  preventing  hemorrhage — a  funnel  to  which  a  rubber  tube 
is  attached,  and  to  the  lower  end  of  the  latter  a  metal  or  hard  rubber 
canula,  for  washing  out  the  abdominal  cavity,  iodoform,  iodoform  gauze, 
antiseptic  cotton,  flannel  bandage  for  the  abdomen,  safety  pins,  two  hypo- 
dermatic syringes,  ether,  brandy,  solution  of  ergotin,  or  fluid  extract  of 
ergot,  and  Tait's  or  other  constrictor,  as  in  preparation  for  hysterectomy, 
should  this  prove  necessary.  He  must  have,  also,  wire,  and  two  long, 
thick  needles.  There  must  be  at  hand  hot  and  cold  water,  basins  and 
towels.  The  operating- table  should  be  narrow ;  the  operator  is  upon 
the  patient's  right  side,  and  his  chief  assistant  upon  the  left.  The  ab- 
dominal incision  must  be  about  six  inches  in  length,  and  is  made 
through  layer  after  layer  in  the  linea  alba — there  is  no  difficulty  in 
finding  this  when  the  tissues  are  stretched  as  they  are  in  pregnancy — 
haemostatic  forceps  being  used  as  required  for  bleeding  vessels ;  as  the 
peritoneum  is  approached,  it  is  advisable  for  the  operator  and  assistant 
to  lift  up  the  tissues  to  be  cut,  each  with  forceps,  and  the  incision  is 
made  between  the  points  of  the  two  instruments.  The  abdominal 
cavity  having  been  opened,  the  incision  if  not  long  enough  is  increased 
by  scissors ;  then  the  uterus  is  brought  out  through  the  opening,  and 
encircled  below  the  ovaries  and  as  close  to  the  neck  as  possible  by  rubber 
tubing,  and  constricted,  or,  instead  of  this  method  of  guarding  against 
hemorrhage,  an  assistant  compresses  with  his  fingers  the  lower  lateral 
part  of  the  uterus.  If  the  uterus  is  opened  outside  the  abdominal 
cavity,  a  few  sutures  are  introduced  at  the  upper  part  of  the  incision  so 


CJESAREAN  OPERATION  AND  ITS  SUBSTITUTES.  627 

as  to  close  it  partially,  and  thus  prevent  the  escape  of  amnial  fluid  or 
blood  into  the  peritoneal  cavity.  Next,  the  anterior  uterine  wall  is 
incised  in  the  median  line — if  the  organ  be  in  situ,  an  assistant  presses 
it  on  either  side  of  the  abdominal  wall  so  as  to  bring  it  close  against  the 
cut  in  the  abdominal  wall,  and  also  corrects  any  obliquity  which  there 
may  be.  The  operator  will  have  in  mind  Leopold's  statement  as  to  de- 
termining the  position  of  the  placenta  (see  page  383) ;  Winckel  states 
we  can  distinguish  previously,  by  the  distinctness  with  which  the  ex- 
tremities are  made  out,  whether  the  placenta  is  attached  in  front  or  not. 
If  it  should  be  found  in  this  position,  we  may  change  the  place  of  incising 
the  uterus.  But  if  the  discovery  is  not  made  until  during  the  incision, 
there  will  be  a  startling  gush  of  blood ;  this  is  only  for  a  moment,  and 
the  operator  does  not  delay  an  instant.  The  incision  of  the  uterus  com- 
pleted, an  assistant  places  the  palmar  surface  of  each  index-finger  at  the 
ends  of  the  opening,  thus  lifting  up  the  uterus,  and  preventing  its  rapid 
retraction.  Next  the  operator  ruptures  the  membranes,  introduces  one 
hand  into  the  sac,  and  the  other  hand  assisting  externally,  brings  the 
child  out  of  the  uterus,  usually  drawing  forth  lower  limbs  and  hips 
first,  shoulders  and  head  last  ]  if  the  incision  in  the  uterus  is  not  large 
enough  for  the  child  to  pass  through,  it  must  be  lengthened  ;  when  the 
child  cries  and  breathing  is  established,  the  cord  is  divided,  and  after 
this  it  is  put  in  charge  of  an  assistant.  The  placenta  and  membranes 
are  delivered  through  the  wound  ;  if  not  spontaneously  detached,  they 
are  manually  separated  from  the  uterine  wall.  The  open  condition  of 
the  cervical  canal  is  next  secured,  and  the  uterine  cavity  is  washed  out 
with  a  1  to  2  per  cent,  solution  of  carbolic  acid,  or  swabbed  out,  accord- 
ing to  Kaltenbach's  direction,  with  a  5  per  cent,  solution  of  carbolic 
acid,  or  1  per  cent,  of  lysol,  or  with  chlorine  water.  Next  the  sutures 
for  the  uterine  incision  are  introduced,  and  here  is  the  great  merit  of 
Sanger's  improvement  in  the  Csesarean  operation,  an  improvement 
which  has  given  the  operation  in  recent  years  a  marvellous  success,  con- 
joining with  deep,  superficial  sutures,  carefully  bringing  the  peritoneal 
margins  in  close  contact,  and  protecting  against  hemorrhage.  Siinger 
and  others  who  employ  these  sutures  use  fine  silk,  much  smaller  than  that 
employed  for  the  deep  stitches.  The  deep  sutures  are  made  down  to, 
but  do  not  include  the  uterine  mucous  membrane ;  there  may  be  five,  six, 
or  seven  of  these,  and  then  probably  twice  as  many  superficial  sutures  : 
the  material  for  the  sutures  is  of  antiseptic  silk.1  After  the  introduc- 
tion of  the  stitches  the  constriction  of  the  uterus,  whether  by  fingers  or 
tube,  is  discontinued.  If  hemorrhage  from  the  wound  follows,  addi- 
tional stitches ;  if  from  relaxed  womb,  uterine  injections  of  hot  water, 
ergot  hypodermatically,  tamponing  with  iodoform  gauze,  and  should 
these  means  fail,  supravaginal  amputation  of  the  uterus,  known  as 
Porro's  operation,  may  be  required.  But  such  hemorrhage  is  excep- 
tional, and  supposing  it  absent,  the  next  step  is  "  the  toilet  of  the  peri- 
toneum," thorough  washing  out  the  abdominal  cavity  with  water  as  hot 
as  can  be  comfortably  borne ;  for  this  purpose  nothing  is  better  than 
the  apparatus  previously  mentioned.  Following  the  thorough  cleans- 

1  Schauta  uses  silver  wire  for  the  deep  sutures.    Fritsch  rejects  the  double  sutures,  nor  does  he 
avoid  in  the  introduction  of  sutures  the  deciduous  membrane,  i 


628  THE  PATHOLOGY  OF  LABOR. 

ing  of  the  abdomiual  cavity  is  the  uniting  the  abdominal  incision  with 
stitches,  silkworm-gut  being  generally  used ;  these  are  chiefly  deep, 
including  the  peritoneum,  and  after  they  are  introduced  and  tied  super- 
ficial sutures  of  catgut  are  employed  at  points  where  the  skin  gaps, 
lodoform  is  sprinkled  upon  the  line  of  incision,  antiseptic  gauze  laid 
next  to  the  abdomen,  then  cotton  batting,  and  finally  a  firmly  fitting 
flannel  bandage  applied.  The  after-treatment  is  that  of  abdominal 
section  in  general,  and  therefore  need  not  be  given. 

G  ASTRO-HYSTERECTOMY,  SUPRA- VAGINAL  AMPUTATION  OF  THE 
UTERUS,  PORRO'S  OPERATION.  Porro,  of  Milan,  in  1876,1  having 
come  to  the  conclusion  that  the  great  mortality  of  gastro-hysterotomy 
was  due  to  leaving  the  injured  uterus  in  the  abdominal  cavity,  performed 
supravaginal  amputation  after  the  extraction  of  the  child.  The  suc- 
cesses were  superior  to  those  obtained  by  the  usual  Csesarean  operation, 
but  with  the  improvement  in  the  method  of  doing  the  latter,  introduced 
by  Sanger,  the  mortality  of  the  two  has  been  reversed,  so  that  the  pro- 
fession generally  prefer  gastro-hysterotomy  to  gastro-hysterectomy  in 
most  cases;  nevertheless,  all  admit  a  limited  field  for  the  latter. 

INDICATIONS  FOR  THE  OPERATION.  Parrish,2  in  his  valuable  con- 
tribution to  the  subject,  states  that  the  operation  should  be  done  when, 
through  unwarranted  delay,  or  by  reason  of  unwarranted  attempts  at 
delivery,  the  uterine  tissues  have  been  seriously  injured,  or  when  the 
child  is  putrid,  or  when  the  patient  is  greatly  exhausted  by  incipient  or 
established  septicaemia,  and  when  there  is  extensive  fibroid  or  fibro- 
cystic  degeneration  of  the  uterine  body.  Among  the  indications  given 
by  Winckel  are  :  Pregnancy  in  a  rudimentary  horn,  the  ovary  on  that 
side  to  be  also  removed,  in  hernia  uteri  gravida  bicornis  iuguinalis,  if  it 
cannot  be  reduced,  in  very  extensive  adhesions  of  the  vault  of  the 
vagina,  and  in  echinococci  of  the  uterine  wall  and  of  the  pelvic  con- 
nective tissue,  which  cannot  be  removed  in  any  other  way  and  which 
make  the  pelvic  canal  absolutely  impassable,  and  in  severe  puerperal 
osteomalacia.  Schultze's  removal  of  the  uterus  seven  days  after 
delivery  has  been  mentioned,  as  well  as  the  indication  given  by  uterine 
hemorrhage  after  gastro-hysterotoray. 

Supravaginal  amputation  of  the  uterus  is  also  indicated  after  abdom- 
inal section  for  ruptured  uterus  if  the  hemorrhage  cannot  be  otherwise 
arrested. 

Porro's  operation  is,  strictly  speaking,  partial  hysterectomy.  Bischoff,  in 
1879,  removed  the  entire  uterus.  According  to  Auvard,  1890,  Bischoff's  opera- 
tion has  been  done  three  times,  always  with  a  fatal  result  to  the  mother. 

METHOD  OF  OPERATING  :  MULLER'S  MODIFICATION.  The  prep- 
aration and  the  abdominal  section  are  the  same  as  for  gastro-hys- 
terotomy ;  so,  too,  the  incision  of  the  uterus  and  the  extraction  of  the 
child,  as  directed  by  Porro.  Miiller,  however,  modified  the  operation 
by  having  the  abdominal  incision  so  large  as  to  permit  eversion  of  the 
body  of  the  uterus,  and  encircling  the  lower  portion  with  a  rubber  tube, 

1  This  operation,  however,  was  first  done  by  Dr.  H.  R.  Storer  in  1868. 

2  First  edition  of  this  work. 


C^ESAREAN  OPERATION  AND  ITS  SUBSTITUTES.  629 

and  then  the  uterus  is  rapidly  opened  and  the  child  extracted.  No 
matter  which  method  is  employed,  the  placenta  and  membranes  are 
left  in  the  uterus.  After  cleansing  the  abdomen  the  upper  portion  of 
the  abdominal  incision  is  closed  with  sutures.  Next  the  uterus  is 
amputated  with  scissors,  knife,  or  by  the  thermo-cautery  about  three- 
fourths  of  an  inch  above  the  constricting  rubber.  If  the  external 
treatment  of  the  pedicle  is  employed,  and  this  is  the  general  rule  with 
operators,  the  stump  is  encircled  with  a  wire  connected  with  a  con- 
strictor, Cintrat's,  Tail's,  or  other,  the  wire  tightened,  the  rubber 
removed,  and  two  long,  thick  needles  passed  through  the  stump ; 
these  transfixion  needles  hold  the  stump  outside  the  abdominal  cavity 
after  the  incision  is  completely  closed.  The  advantages  in  using  wire 
is  that  in  case  hemorrhage  occurs,  as  may  happen  from  shrinking  of  the 
pedicle,  a  few  turns  of  the  screw  tighten  the  wire  so  that  the  bleeding 
is  promptly  arrested.  Mr.  Tait  refers  to  the  operation  as  the  easiest 
"  in  abdominal  surgery,  and  every  country  practitioner  ought  always  to 
be  ready  to  perform  it.  No  special  instruments  are  required — nothing 
but  a  knife,  a  piece  of  rubber  drainage-tube,  two  or  three  knitting- 
needles,  and  a  little  perchloride  of  iron."  The  stump  is  brushed  over 
with  a  solution  of  the  perchloride  of  iron.  The  transfixion  needles  are 
removed  in  ten  to  twelve  days.  In  case  the  intra-peritoneal  treatment 
of  the  stump  is  selected,  the  operator  begins  by  carefully  stitching  the 
mucous  membrane  of  the  stump  with  silk  sutures  ;  next  the  muscular 
tissue  is  stitched  over  this,  and  finally  the  serous  above  it.  If  any 
bleeding  occurs  upon  removing  the  rubber  tube,  additional  stitches  are 
taken,  or  the  afferent  vessels  of  the  broad  ligaments  ligated.  When  all 
bleeding  is  stopped  the  pedicle  is  dropped  in  the  abdominal  cavity. 

GASTRO-ELYTROTOMY.  This  operation  was  first  suggested  by  Jorg,  in  1807, 
attempted  by  Ritgen  in  1821,  advocated  by  Auguste  Baudelocque  in  1823, 
twenty  years  later  attempted  twice  by  him,  the  first  attempt  a  failure,  but  in  the 
second  a  dead  child  delivered  and  the  mother  perishing  seventy  hours  afterward, 
done  in  Italy  in  1857,  the  child  saved  but  the  mother  dying,  was  again  brought 
before  the  profession  by  Thomas  in  1870.  Whatever  of  fame  and  success  the 
operation  had  during  the  brief  period  of  its  limited  acceptance  is  chiefly  due  to 
T.  Gaillard  Thomas.  But,  as  Winckel  states,  the  operation  rested  on  false 
premises  regarding  the  peritoneum.  Its  success,  too,  is  inferior  even  to  the 
operation  of  Porro.  Clark1  gives  the  maternal  mortality  as  54  per  cent.,  and  the 
foetal  as  36  per  cent.  The  special  purpose  of  the  operation  was  to  avoid  exposing 
the  peritoneal  cavity,  and  it  accomplished  this  by  making  an  opening  into  the 
vagina,  beginning  with  an  incision  upon  one  side  about  an  inch  above  Poupart's 
ligament ;  the  tissues  were  divided  to  the  peritoneum,  and  this  was  separated 
until  the  lateral  cul-de  sac  of  the  vagina  was  reached  ;  the  wound  was  four  and 
a  half  to  five  inches  long  ;  a  small  incision  was  made  into  the  vagina,  and  the 
opening  enlarged  by  tearing ;  the  os  was  dilated,  and  child  and  placenta  were 
removed  through  the  abdomino-vaginal  wound. 

"  The  operation  has  no  future."  Winckel,  in  condemning  it,  hopes  that  his  lines 
may  hasten  it  once  more  to  a  silent  burial,  and  that  it  may  have  no  resurrection. 

POST-MORTEM  DELIVERY.  The  Csesareau  operation  was  originally 
done  in  case  of  women  advanced  in  pregnancy  dying  undelivered.  This 
was  the  civil  law  in  Rome2  dating  from  the  time  of  Numa  Pompilius. 

1  Contribution  to  k  1' Etude  de  la  laparo-elytrotomie,  1887. 

2  In  Plutarch's  Lives  it  is  stated  that  Scylla  having  died,  his  wife,  "  Valeria  was  afterward 
delivered  of  a  daughter,  named  Posthuma ;  for  so  the  Romans  call  those  who  are  born  after  the 


630  THE  PATHOLOGY  OF  LABOR. 

But  the  fact  that  post-mortem  delivery  by  an  abdomino-uterine  incision  was 
recognized  in  ancient  mythology — as  is  exhibited  by  the  history  of  the  birth  of 
Bacchus,  the  god  of  wine,  and  that  of  ^sculapius,  the  god  of  medicine — renders 
it  probable  that  the  operation  is  still  older. 

The  Church,  as  Hubert  remarks,  merely  reproduced  the  injunction  of  the 
Roman  law  in  the  following  degree  of  its  Ritual :  Si  mater  prsegnans  mortua  ait, 
iructus  quam  primum  caute  extrahatur. 

As  has  already  been  indicated,  the  method  of  delivery  after  the  mother's  death, 
exclusively  recognized  in  ancient  times,  and  indeed  that  which  has  most  gen- 
erally been  employed  since,  was  the  Csesarean  section.  Unfortunately,  in  some 
instances  in  which  it  has  been  resorted  to  the  woman  was  not  dead,  and  more 
than  one  operator  has  fled  horror  stricken. upon  finding  the  manifestations  of 
life  when  he  thought  his  incisions  were  made  upon  a  corpse. 

ThSvenot1  has  earnestly  contended  for  delivery  through  the  natural 
passage,  as  successfully  accomplished  by  the  Italian  school,  especially 
by  Rizzoli,  and  asserts  that  the  post-mortem  Csesarean  operation  belongs 
to  another  age  and  ought  to  disappear  from  our  practice.  Depaul,  in 
1861,  said,  "  I  cannot  too  strongly  insist,  with  almost  all  those  who  have 
studied  this  subject,  upon  the  advantages  which  extraction  of  the  infant 
by  the  natural  passage  gives.  One  ought  not  to  hesitate  in  the  appli- 
cation of  a  bistoury  to  the  cervix  and  relieving  resistance  by  multiple 
incisions.  There  can  be  thus  obtained  in  a  few  seconds  sufficient  dila- 
tation to  perform  version  or  to  apply  the  forceps."  There  have  been 
several  successful  deliveries  effected  in  this  way,2  but,  of  course,  it  is 
only  applicable  in  normal  conditions  of  the  pelvis,  and  will  be  most 
successful  when  the  death  of  the  mother  occurs  during  labor.  The 
method  is  especially  applicable  in  cases  of  apparent  death,  or  when 
there  is  doubt  in  regard  to  the  question  as  to  whether  life  is  actually 
extinct. 

If  the  Csesarean  operation  is  employed,  the  same  precautions  should 
be  used  as  if  it  were  being  done  upon  the  living  subject.  Only  a  small 
minority  of  children  can  be  thus  saved  ;  the  successes  generally  occur 
only  in  those  cases  in  which  the  mother  has  died  suddenly,  and  when 
the  operation  is  done  within  twenty-five  minutes  after  her  death. 

father's  death."  It  might  be  justly  implied  from  this  that  the  removal  from  a  dead  mother  ot  a 
living  child  was  unknown  among  the  Romans.  Readers  of  Shakspeare  will  be  reminded  in  the 
play  of  Cymbeline  of  the  words  spoken  by  the  apparition  of  the  father  of  Leonatus  Posthumus  : 

Hath  my  poor  boy  done  aught  but  well, 

Whose  face  I  never  saw  ? 
I  died  whilst  in  the  womb  he  stay'd, 

Attending  Nature's  law. 

By  the  way,  the  mother's  words,  following  those  of  the  apparition,  point  clearly  to  a  successful 
Csesarean  operation: 

Lucina  lent  me  not  her  aid, 

But  took  me  in  my  throes ; 
That  from  me  was  Posthumus  ript,  etc. 

1  De  1' Accouchement  artiflciel  par  les  voies  naturelles  substitute  a  1'opgration  Cesarienne  post- 
mortem.   Paris,  1878. 

2  Dr.  Barton  C.  Hirst  has  reported  a  case  in  which  the  post-mortem  Caesarean  operation  was 
avoided  by  dilatation  of  the  os  while  the  woman  was  dying  ;  the  dilatation  was  accomplished  in 
a  few  minuies,  and  a  living  child  extracted.    Philadelphia  Medical  News,  May  24,  1890. 

According  to  Auvard,  this  method  of  delivery,  accouchement  forc6  pendant  1'agonie,  was  directed 
by  Costa  in  1827.  He  states  that  unless  there  is  an  urgent  indication,  it  is  preferable  not  to 
trouble  the  final  minutes  of  the  dying  by  an  intervention  which  can  be  as  well  done  after  life 
ceases.  Nevertheless,  in  Dr.  Hirst's  case  there  does  not  seem  to  have  been  any  disturbance  of  the 
patient  by  the  intervention.  Millot,  De  I'Obstetrique  en  Italie,  1882,  gives  14  cases,  the  first  in 
1858,  the  last  in  1870.  of  this  method  of  delivery,  5  of  the  14  women  suffering  from  pulmonary 
phthisis.  Only  3  of  the  14  children  were  delivered  alive. 


CHAPTER    XIV. 

EMBRYOTOMY. 

EMBRYOTOMY  includes  all  operations  employed  to  lessen  the  size  ©f 
the  foetus,  facilitating  or  rendering  possible  its  transmission  through  the 
birth-canal.  These  operations  embrace,  therefore,  perforation  of  the 
cranium  and  removal  of  its  contents,  cephalotripsy,  cranioclasm,  break- 
ing up  the  base  of  the  cranium — as  by  transforatiou,  the  method  of 
Hubert,  or  by  the  basiotribe  of  Taruier,  or  by  the  basilyst  of  Simp- 
son— and  the  division  of  the  head  into  sections,  or  lamination,  decolla- 
tion, evisceration,  and  spondylotomy. 

Embryotomy  is  one  of  the  oldest  obstetric  operations,  directions  for  its  per- 
formance having  been  given  by  Hippocrates.  All  obstetricians  recognize  it  as 
not  only  a  right,  but  also  a  duty  in  certain  circumstances,  to  perform  embry- 
otomy  upon  the  dead  foetus ;  while  some,  and  the  number  is  steadily  increasing, 
condemn  its  performance  when  the  child  is  alive ;  some,  indeed,  have  had  so 
strong  a  repugnance  to  directly  sacrificing  the  life  of  the  child  that  they  have 
done  it  indirectly,  waiting  until  it  died  before  resorting  to  the  operation,  thereby 
in  no  sense  evading  the  responsibility  for  its  death,  and  at  the  same  time  by  delay 
adding  to  the  perils  of  the  mother.  The  principle  of  morals  upon  which  most 
obstetricians  rest  the  right  to  sacrifice  the  child  for  the  sake  of  the  mother  is  a 
very  old  one,  and  has  met  with  general  acceptance ;  that  principle,  clearly 
enunciated  by  Cicero,1  for  example,  and  sustained  in  general  by  moralists  of  all 
ages,  is  that  if  two  lives  are  in  such  peril  that  both  cannot  be  saved,  but  one 
will  be  by  the  sacrifice  of  the  other,  let  that  life  which  is  of  least  value  to  the 
State,  or  to  society,  perish.  It  is  unnecessary  to  show  that  the  adult  woman 
with  her  various  domestic  and  social  duties,  has  a  life  of  greater  value  than  that 
of  the  unborn  child ;  and,  therefore,  while  the  duty  of  the  obstetrician  is  to  save, 
both  when  he  can,  if  either  is  to  be  sacrificed  let  it  be  that  of  the  latter — in  other 
words,  if  in  a  given  case  embryotomy  is  a  less  risk  to  the  mother  than  Csesarean 
section,  the  former  should  be  selected.  This  is  a  rule  of  obstetric  ethics  which 
cannot  be  set  aside.  Fortunately  the  brilliant  successes  recently  had  by  a  few 
operators  in  Germany  render  it  highly  probable  that  embryotomy  upon  the  living 
foetus  will  soon  be  restricted  to  very  narrow  limits. 

Symphyseotomy,  too,  promises  much  in  lessening  the  occasion  for  craniotomy 
upon  the  living  child.  Nevertheless,  there  are  conditions  which  clearly  justify 
it.  For  example,  in  case  of  hydroc'ephalus,  or  in  that  of  a  monstrosity,  causing 
an  obstacle  to  delivery,  we  do  not  hesitate  to  sacrifice  the  life  of  the  child  for 
the  safety  of  the  mother.  Further,  in  case  of  threatened  rupture  of  the  uterus, 
immediate  delivery  is  imperative;  and  frequently  this  delivery  can  be  most 
promptly  accomplished  by  lessening  the  size  of  the  child. 

Winckel  admits  craniotomy  upon  the  living  child,  first,  if  its  life  is  much  en- 
dangered so  that  its  chances  of  being  saved  are  improbable,  in  order  to  protect 
the  mother,  as  far  as  possible,  from  the  dangers  of  a  more  difficult  operation ; 
and,  second,  if  a  relative  indication  for  the  Csesarean  section  exists — that  is,  if 
the  child  cannot  be  delivered  through  the  pelvis  as  it  is,  and  the  mother  firmly 
refuses  the  operation.  "The  percentage  of  maternal  deaths  in  the  hands  of 

1  "  Quid,  si  in  una  tabula  sint  due  naufragi,  hique  sapientes,  sibine  utervis  rapiat,  an  alter  cedat 
alteri?  Cedat  vero  ;  sed  ei,  cuius  magis  intersit  vel  sua,  vel  reipublicse  causa,  vivere.  Quid,  si 
haec  paria  in  utroque?  Nullum  erit  certamen,  sed,  quasi  sorte  aut  micando  victus,  alteri  cedat 
alter."  (Cicero  de  Offlciis,  Book  III.,  xxiii.  Pereya'sed.) 


632  THE  PATHOLOGY  OF  LABOR. 

skilful  operators  is  reckoned  at  0  after  perforation  and  as  at  least  8.4  per  cent, 
after  the  Csesarean  section.  The  former  is  entirely  free  from  danger,  and  the 
latter,  especially  in  the  hands  of  an  inexperienced  man,  can  only  be  designated 
as  quite  dangerous;  therefore,  perforation  of  the  living  child  will  be  considered 
justifiable  in  many  cases."1  Winckel  also  states  that  craniotomy  must  not  be 
performed  on  a  living  child  without  the  mother's  consent. 

Auvard  says :  "  If  the  life  of  the  child  were  as  valuable  as  that  of  the  mother 
there  could  be  no  hesitation  in  giving  the  preference  to  hysterotomy ;  but  the 
appreciations  are  different  in  this  regard,  and  while  the  Caesareans  say  that  the 
life  of  a  perfectly  developed  infant  is  more  precious  than  that  of  a  woman  unfit 
for  procreation,  the  anti-Csesareans  reply  that  the  life  of  the  newborn,  sur- 
rounded by  so  many  dangers,  cannot  be  regarded  as  equal  to  that  of  a  healthy 
woman.'1 

"  If  it  were  your  wife  or  your  child,  what  would  you  do?1'  The  Csesareans 
are  embarrassed,  for  if  obedient  to  their  principles,  they  will  be  considered  bad 
husbands.  On  the  other  hand,  the  anti-Csesareans  will  seem  to  be  bad  fathers, 
for  they  do  not  hesitate  to  sacrifice  their  child.  In  this  question,  which  ought 
to  be  purely  scientific,  it  is  better  that  sentiment  should  not  enter,  or  it  becomes 
insoluble.  However,  in  accepting  that  the  life  of  the  mother  has  a  greater  value 
than  that  of  the  child  awaiting  birth,  we  may  attempt  to  indicate  the  better 
choice  between  the  operations,  though  confessing  that  it  is  arbitrary  and  ad- 
mits of  discussion.'' 

Cancer  of  the  uterus  or  of  the  vagina  suggests  hysterotomy  rather  than  em- 
bryotomy,  is  generally  held  by  obstetric  authorities.  Again,  if  the  pelvic  con- 
tractions be  such  that  a  living  child  may  be  born  were  premature  labor  induced, 
and  the  pregnancy  is  at  term,  embryotomy  is  selected  with  the  hope  that  a  sub- 
sequent pregnancy  may  occur  and  be  prematurely  terminated,  is  an  opinion 
expressed  by  Auvard.  The  more  difficult  cases  for  decision  are  those  in  which 
it  is  impossible,  on  account  of  the  pelvic  deformity,  for  a  woman  to  give  birth  to 
a  living  child,  though  premature  labor  be  induced,  and  embryotomy  can  be  done 
with  little  risk  to  the  woman's  life.  Here  Auvard,  Winckel,  and,  indeed,  the 
majority  of  obstetricians,  would  leave  the  decision  to  the  woman  herself. 

I  think  most  practitioners  will  coincide  with  the  opinion  of  Naegele,  in  saying 
that  if  the  indication  is  only  relative  and  the  mother,  in  sound  mind  and  after 
mature  reflection,  positively  refuses  to  submit  to  the  Csesarean  operation,  it 
would  be  an  unjustifiable  cruelty  to  compel  her  to  undergo  it. 

Dr.  Jaggard  has  given,  in  the  American  Journal  of  Obstetrics,  the 
following  as  the  expression  of  Carl  Braun's  views  in  regard  to  the  rela- 
tive indication  for  the  Csesarean  operation  : 

Ca3sarean  section  on  the  living  woman,  for  the  preservation  of  the  living  foetus 
in  pelvic  deformity — in  which  the  child,  dead  and  diminished  in  volume,  can  be 
extracted  through  the  pelvic  canal,  and  the  health  of  the  mother  can  with  prob- 
ability be  preserved  by  the  perforation  of  the  child's  head — is  not  permissible 
under  the  following  conditions : 

a.  When  the  parturient  woman,  in  full  consciousness  and  without  any  direct 
coercion,  declines  Csesarean  section. 

b.  When  the  parturient  woman  is  rendered  unconscious  by  disease  (eclampsia, 
meningitis,  apoplexy,  etc.),  by  medicines  (chloroform,  ether),  by  poisons,  or  in- 
toxicating drinks. 

c.  When  the  child's  life  has  been  imperilled  by  uterine  contractions,  attempts 
at  version,  or  the  forceps,  or  when  the  child  is  deformed  or  not  viable. 

For  a  series  of  years  not  a  single  parturient  woman  in  the  Vienna  Lying-in 
Hospital  has  determined  to  submit  to  Csesarean  section  upon  the  ground  of  the 
relative  indication. 

INDICATIONS.  Those  relating  to  the  pelvis  or  caused  by  cancer  of 
the  uterus  or  vagina  have  already  been  stated.  The  operation  has  also 

1  Runge  gives  the  maternal  mortality  in  general  at  18  to  20  per  cent. 


EMBRYOTOMY. 


633 


been  done  iu  hypertrophic  elongation  of  the  cervix  and  in  cicatricial 
contraction  of  the  vagina.  Excessive  size  of  the  foetus,  and  a  neglected 
shoulder  presentation  in  which  version  is  impossible  or  would  be  at- 
tended with  imminent  danger  of  rupture  of  the  uterus,  are  indications. 
It  may  be  necessary  in  a  brow  or  parietal  presentation,  or  in  that  of 
the  face  when  anterior  rotation  is  impossible. 

CRANIOTOMY.  Most  frequently  reduction  of  the  size  of  the  foetal 
head  is  necessary,  and  the  first  step  is  perforation.  So,  too,  perforation 
precedes  the  application  of  the  cephalotribe,  or  its  most  recent  modifi- 
cation, the  basiotribe,  or  of  the  crauioclast. 

PERFORATION.  Reduction  of  the  size  of  the  head,  whether  this 
comes  first  or  last,  is  necessary.  Supposing  the  head  presents,  the  first 
step  is  perforation  of  the  cranium.  In  order  that  this  may  be  done 
readily  and  safely,  the  head  must  be  held  by  an  assistant,  who  presses 
upon  it  through  the  abdominal  wall  with  his  hand  during  perforation. 


o 

, — -* 

<?.TIEMANN=CO. 
SMELLIE'S  SCISSORS. 

FIG.  256. 


NAEGELE'S  PERFORATOR. 
FIG.  257. 


BLOT'S  PERFORATOR. 
FIG.  258. 


MARTIN'S  TREPHINE. 

Carus  was  the  first  to  apply  forceps  in  order  to  secure  this  immobility,  a  prac- 
tice which  many  have  imitated.  The  instrument  selected  for  perforation  may  be 
Smellie's  scissors,  or  Naegele's  perforator,  or  Blot's,  or  a  trephine,  Martin's, 
for  example. 

Winckel  states  that  he  always  prefers  scissors  if  a  fontanelle  or  suture  can  be 
reached,  but  if  it  cannot  be,  and  the  cranial  bones  are  very  hard,  he  uses  a 
trephine. 


634  THE  PATHOLOGY  OF  LAS  OR. 

Fritsch  condemns  all  trephine  perforators — those  of  Kiwisch-Leissnig  and  of 
Braun  among  them — because  of  the  difficulty  in  thoroughly  cleaning  them ;  for 
in  order  that  this  can  be  properly  done,  they  must  be  returned  to  the  instru- 
ment-maker each  time  after  they  are  used.  If  the  operator  has  Tarnier's  basio- 
tribe,  or  the  similar,  and  probably  better,  instrument  of  Auvard,  he  will  need 
neither  scissors  nor  trephine. 

FIG.  259. 


SIMPSON'S  BASILYST. 


The  patient  occupies  the  position  advised  for  the  application  of  the 
forceps;  anaesthesia  is  usually  unnecessary.  The  operator,  after  the 
vagina  has  been  washed  out  with  an  antiseptic  solution,  and  the  hands 
and  instruments  have  been  made  aseptic,  introduces  two  fingers  of  the 
left  hand  into  the  vagina  and  brings  their  tips  in  contact  with  the  foetal 
head  ;  the  scissors,  or  perforator,  now  held  with  the  right  hand,  has  the 
blades  guided  along  the  palmar  surface  of  the  fingers  in  the  vagina 
until-  their  points  are  brought  in  contact  with  the  foetal  skull  and  placed 
perpendicularly  to  the  bony  surface.  It  is  better  to  perforate  bone  than 
to  enter  through  a  suture  or  a  fontanelle,  for  then  the  opening  is  more 
likely  to  remain  patent  instead  of  being  closed  by  the  approximation  of 
the  foetal  bones  under  compression.  The  next  step  is,  while  carefully 
guarding  the  instrument  from  slipping,  by  a  boring  movement  to  make 
its  points  penetrate  through  the  bone ;  when  this  is  accomplished  the 
blades  are  caused  to  enter  as  far  as  the  shoulders  of  the  instrument,  then 
opened  so  as  to  divide  the  bone,  and  after  this  closed,  given  a  quarter 
rotation  and  again  opened,  so  that  an  incision  perpendicular  to  the  first 
one  is  made.  The  next  step  is  to  thrust  the  scissors  deeply  in  the 
cranial  cavity,  move  the  blades  in  different  directions,  so  as  thoroughly 
to  break  up  the  brain  substance,  including  the  medulla  oblongata — if, 
by  misfortune,  it  has  been  necessary  to  operate  upon  the  living  foetus — 
for  more  than  once  after  a  craniotomy,  when  this  precaution  was  not 
taken,  the  child  has  been  born  alive  and  even  lived  for  some  days  in  a 
horribly  mutilated  condition,  greatly  to  the  distress  of  the  family,  if 
not  to  the  disgrace  of  the  obstetrician. 

In  case  a  trephine  be  used  for  perforation,  the  instrument  must  be 
introduced  and  brought  to  press  firmly  upon  the  bony  part  selected,  and 
held  in  position  with  the  fingers  of  the  left  hand,  while  the  right  hand 
is  used  to  give  slow  rotary  movements  to  the  crown  after  the  screw  has 
penetrated  the  bone. 

After  perforation  the  nozzle  of  a  syringe  is  introduced  into  the  arti- 
ficial opening  and  a  stream  of  warm  carbolized  or  creolin  water  thrown 
in,  so  that  the  brain  substance  is  washed  out.  The  delivery  may  now 
occur  spontaneously,  or  the  foetus  may  be  extracted  with  the  crotchet, 
or  a  cranioclast  may  be  used,  an  instrument  which,  if  carefully  used, 
does  not  deserve  the  reproaches  that  have  been  cast  upon  it  (Figs.  260, 
261,  and  262). 


EMBRYOTOMY. 


635 


Of  course,  if  the  practitioner  has  at  hand  a  cranioclast  or  a  cephalotribe,  de- 
livery can  generally  be  more  promptly  accomplished  with  either  than  with  the 
crotchet;  but  with" most  practitioners  the  last  is  more  available  than  the  other 
instruments.  In  order  to  prevent  the  injury  that  may  be  done  the  mother's  soft 


FIG.  260. 


CROTCHET. 


parts  by  the  crotchet  slipping  a  guarded  instrument  has  been  invented,  but  it  will 
prove  a  most  inefficient  one  for  traction ;  it  is  guarded  alike  from  doing  any  good 
as  well  as  any  harm.  The  hook-like  end  of  the  instrument  is  introduced  into 


FIG.  261. 


SIMPSON'S  CRANIOCLAST. 


the  foetal  skull,  a  firm  hold  secured,  and  two  fingers  placed  upon  the  outside  of 
the  head,  directly  opposite  the  point  at  which  the  instrument  has  caught,  so  as 
to  prevent  its  slipping,  or  if  it  does,  to  guard  the  vagina  from  harm  ;  if  slipping 


BRAUN'S  CRANIOCLAST. 


occur,  another  part  of  the  foetal  head  should  be  sought  and  a  firmer  hold  se- 
cured. Care  must  be  taken  not  to  .tear  the  foetal  scalp,  for  this  protects  the 
mother's  parts  from  being  injured  by  the  otherwise  exposed  edges  of  bones  or  of 
their  fragments. 

CRANIOCLASM.  In  most  cases  the  cranioclast  is  one  of  the  most  effi- 
cient instruments  not  only  for  breaking  up  the  bones  of  the  skull,  but 
also  for  extraction.  The  cranioclast  is  the  invention  of  the  late  Sir 
James  Simpson.  It  is  composed  of  two  separate  blades,  fastened  by  a 
button  joint,  one  for  introduction  within,  the  other  to  be  placed  without 
the  skull ;  when  applied  and  locked  the  concavity  of  the  external  blade 
fits  upon  a  convexity  of  the  internal  one,  a  portion  of  the  fcetal  skull 
being  firmly  included  between  the  two.  The  cranioclast  as  now  made 
includes  a  transverse  arm  connecting  the  ends  of  the  handles ;  this  arm 


636  THE  PATHOLOGY  OF  LABOR. 

has  a  screw,  and  a  nut,  which,  after  its  application,  causes  the  handles  to 
be  brought  closer  together  and  makes  them  immovable,  so  that  a  firmer 
fixed  grasp  upon  the  foetal  head  is  secured. 

CEPHALOTRIPSY.  The  cephalotribe,  devised  by  the  younger  Baudelocque 
(nephew  of  the  great  obstetrician)  in  1829,  consists  of  two  strong  forceps 
branches,  in  some  instruments  straight,  but  in  others  having  the  pelvic  curva- 
ture of  forceps ;  the  blades  are  very  narrow,  so  as  to  admit  of  their  introduction 
into  a  contracted  pelvis,  and  in  most  instruments  solid,  but  in  Bailly's  and  in 
some  others  fenestrated — a  single  fenestra  in  each  blade  in  some,  but  in  others, 
as  Tarnier's,  three.  The  instrument  is  provided  with  a  transverse  bar  made  as 
a  screw  and  applied  to  the  ends  of  the  handles.  The  blades  are  applied  to  the 
sides  of  the  foetal  head,  which  is  then  compressed  by  means  of  the  powerful 
screw  at  the  handles.  Perforation  ought  always  to  precede  the  application  of  the 
cephalotribe,  but  it  is  unnecessary  to  wash  out  the  cranial  cavity,  for  the  strong 
pressure  to  which  the  head  is  subjected  will  force  out  the  contents.  In  most  of 
cases  in  which  the  cephalotribe  is  necessary  there  is  such  narrowing  of  the  inlet 
that  the  head  is  in  a  transverse  direction,  and  the  blades  of  the  instrument  seize 
it  in  the  direction  of  the  suboccipito-fronbal  diameter.  But  as  it  is  important  to 
break  up  the  base  of  the  cranium,  Wasseige1  advises  when  one  cannot  seize  the 
head  by  the  biparietal  diameter,  to  diagonalize  it,  as  far  as  possible,  before  the 
application  of  the  instrument ;  "  that  is,  we  bring  the  head  anterior  and  then 
apply  the  instrument  in  the  oblique  pelvic  diameters ;  these  applications  can  be 
made  where  the  pelvic  narrowing  is  between  5.5  centimetres  and  7.5  centimetres 
— that  is,  between  2.1  and  2.7  inches,  while  below  the  former  oblique  applica- 
tions are  impossible." 

After  the  crushing,  which  must  be  done  slowly,  one  or  two  fingers  should  be 
introduced  to  ascertain  that  the  part  of  the  head  which  has  been  widened  in 
opposition  to  that  which  narrowed  lies  in  the  longest  pelvic  diameter,  and  that 
no  spiculae  of  bone  are  exposed  which  will  tear  the  mother's  soft  parts  in  the 
extraction  of  the  head ;  and  if  these  be  found,  the  fingers  are  kept  in  the  vagina 
to  protect  it  from  injury  during  the  operation.  To  bring  the  long  diameter  of 
the  foetal  head  in  correspondence  with  that  of  the  pelvis,  a  quarter  rotation  of 
the  instrument,  still,  of  course,  retaining  the  head  in  the  grasp  of  the  instru- 
ment, is  made,  and  then  traction  exerted  as  in  forceps  delivery.  In  some  instances 
before  the  latter  can  be  effected,  it  is  necessary  to  remove  the  cephalotribe, 
especially  if  the  instrument  slip,  and  apply  it  in  another  direction  so  as  com- 
pletely to  crush  the  skull.  If  extraction  remains  impossible  after  repeated 
crushings,  some  operators  advise  waiting  a  few  hours  until  uterine  contractions 
have  so  moulded  the  head  that  its  transmission  becomes  possible. 

It  may  be  added  that  the  cephalotribe  is  an  instrument  which  has  been 
almost  superseded  by  the  cranioclast,  many  obstetricians  rejecting  it. 

LAMINATION.  This  name  is  given  to  the  process  of  dividing  the  head  into 
two  or  more  segments.  The  first  method  is  that  of  Van  Huevel ;  in  1842  he 
devised  his  forceps-saw,  and  successfully  applied  it  in  1844.  The  fundamental 
idea  is  the  section  of  the  cranium  by  a  saw  acting  from  below  above  between 
the  blades  of  a  forceps,  and  dividing  the  head,  more  especially  the  base  of  the 
cranium,  into  two  portions.  Other  varieties  of  the  forceps-saw  have  since  been 
invented. 

The  expense  of  the  instrument  and  its  somewhat  complicated  character  will 
prevent  its  general  use  in  craniotomy.  Barnes  says  that  it  is  difficult  or  impos- 
sible to  apply  when  the  conjugate  is  reduced  to  2  inches,  or  even  to  2.5 ;  Was- 
seige, however,  states  that  the  instrument  can  be  used  when  the  conjugate  is 
only  30  millimetres,  2.1  inches. 

Barnes,  1869,  showed  that  section  of  the  foetal  head  could  be  made  with  the 
wire  6craseur,  and  this  simple  method  is  to  be  preferred. 

BREAKING  THE  BASE  OF  THE  FOETAL,  HEAD.  Various  instruments  have  been 
proposed  for  this  purpose,  but  only  three  will  be  mentioned  :  the  transforateur 
of  Hubert,  devised  in  1860;  the  basilyst  of  Simpson,  and  the  basiotribe  of 
Tarnier.  The  first  consists  of  a  firm  rod  of  steel,  terminating  at  one  end  in  a 

i  Op.  cit. 


EMBRYOTOMY. 


637 


transverse  handle,  and  at  the  other  in  a  pear-shaped  screw  with  a  sharp,  stiletto- 
like  point,  and  of  a  protecting  branch  which  is  attached  to  the  rod  ;  it  is  shaped 
like  the  forceps  blade,  and  has  a  conical  opening  in  its  lower  end  to  receive  the 
point  of  the  perforator.  This  point,  covered  with  wax,  or  concealed  by  the 
finger  of  a  rubber  glove,  when  introduced,  is  made  to  penetrate  the  cranial  vault, 
either  through  a  bone,  a  suture,  or  a  fontanelle,  and  then  by  movements  of  rota- 
tion the  opening  is  gradually  enlarged  until  the  entire  pear-shaped  portion 
enters;  the  next  step  is  by  free  movements  of  the  instrument  to  break  up  the 
cerebral  tissue.  After  this  the  point  is  guided  to  the  occipital  foramen,  and  when 

FIG.  263. 


TARNIEK'S  BASIOTRIBE  ;  THE  PARTS  UNITED. 


this  is  found,  the  former  should  be  directed  toward  the  chin,  and  when  at  a  dis- 
tance of  4  or  5  centimetres,  1.5  to  1.9  inches,  in  front  of  the  foramen  the  sella 
turcica  is  reached,  which  is  then  perforated  by  means  of  rotary  movements,  and 
the  protecting  branch  is  applied  just  opposite  upon  the  foetal  head.  The  basi- 
lyst  of  Alexander  R  Simpson,  which  Wasseige  states  is  only  a  modification  of 
the  diatripteur  of  Didot,  was  presented  to  the  Edinburgh  Obstetrical  Society, 
January,  1880,  and  an  improvement  of  it  January,  1883,  when  the  inventor  re- 
ported a  case  in  which  basilysis  was  successfully  employed  in  dystocia  from 
hypertrophic  elongation  of  the  cervix  (Fig.  257). 

The  instrument  has  also  been  successfully  used  directly  to  break  up  the  base 
of  the  skull  in  narrowing  of  the  pelvis;  in  one  instance  the  transverse  diameter 


638 


THE  PATHOLOGY  OF  LABOR. 


of  the  base  was  reduced  from  3  to  2  inches.  Whether,  as  Simpson  has  said, 
basylisis  is  the  operation  of  the  future  or  not,  he  certainly  has  invented  a  simple 
and  ingenious  instrument  for  accomplishing  it. 

The  basiotribe1  of  Tarnier  was  presented  to  the  Paris  Academy  of 
Medicine,  December,  1883.  It  combines  an  excellent  perforator  of  the 
cranial  vault  and  a  cranioclast ;  it  does  not  break  the  base  of  the  head, 
as  do  the  instruments  of  Hubert  and  Simpson,  by  penetrating  it,  but 
by  crushing.  Fig.  263  represents  the  several  parts  of  which  the  basio- 
tribe is  composed,  united. 

In  operating,  the  perforator  is  made  to  penetrate  the  cranial  vault, 
after  which  the  left  or  short  blade  of  the  instrument  is  introduced  and 
fastened  by  the  catch,  C,  and  then  the  right  or  long  blade ;  the  screw 
is  then  fastened  to  the  end  of  the  handles,  and  turned  until  sufficient 
crushing  is  effected. 


FIG.  264. 


FIG.  265. 


APPLICATION  OF  TARNIER'S  BASIOTRIBE. 


BASIOTRIPSY  ACCOMPLISHED. 


PERFORATION  IN  PRESENTATION  OF  THE  FACE.     This  is  more 
difficult  than  perforation  in  vertex  presentation  ;  it  may  be  done  through 


1  It  has  since  been  usefully  modified  by  Barr. 


EMBRYOTOMY.  639 

the  palatine  vault,  through  one  of  the  orbits,  or  through  the  frontal 
bone,  the  last  being  preferred. 

PERFORATION  IN  HEAD-LAST  LABOR.  An  assistant  holds  the  body 
of  the  child  to  one  side,  and  the  operator  perforates  the  head  at  one  of 
the  posterior  lateral  fontanelles.  Chailly  advised  that  the  opening  be 
made  through  the  palatine  vault,  condemning  acting  either  upon  the 
forehead  or  the  occiput,  because  the  point  of  the  perforating  scissors 
could  not  be  directed  perpendicularly,  but  must  be  placed  obliquely  to 
either  bony  surface,  and  hence  were  liable  to  slip,  injuring  the  mother. 

In  concluding  the  subject  of  craniotomy  it  is  to  be  remarked  that  the 
student  should  not  think  it  a  very  simple  and  easy  operation  that  can 
be  quickly  performed  and  delivery  promptly  effected.  This  is  true  in 
some  cases  only,  but,  in  many,  difficulties  attend  almost  every  step  in 
the  process,  and  in  rare  cases  the  delivery  may  not  be  accomplished  for 
hours.  Therefore  the  operation  is  not  to  be  undertaken  unless  the  proof 
be  clear  that  it  furnishes  the  best  chance  for  the  mother,  and,  on  the 
other  hand,  not  delayed  until  her  powers  are  so  exhausted  that  she  is 
liable  to  perish  before  or  after  its  accomplishment. 

DECOLLATION,  DEROTOMY,  OR  DECAPITATION.  In  case  of  shoulder 
presentation,  when  turning  is  impossible  from  the  condition  of  the 
uterus,  or  from  the  presenting  part  being  wedged  in  the  pelvis,  it  is 
necessary  in  most  cases  to  divide  the  neck.  This  operation  may  be  done 
with  the  scissors  of  Dubois,  with  the  decapitation  hook  of  Braun,  or 
simply  by  means  of  a  piece  of  strong  twine1  thrown  around  the  neck,  and 
used  as  a  saw,  to-and-fro  motion  given  it,  the  maternal  parts  being  pro- 
tected from  injury  by  the  ends  of  the  string  being  passed  through  a  tubu- 
lar speculum,  and  in  two  or  three  minutes  the  neck  will  be  divided.  If 
the  scissors  of  Dubois  is  used,  or  the  hook  of  Braun,  the  first  step  is  to 
pull  down  the  presenting  shoulder  by  traction  on  the  corresponding 
arm  ;  the  next  step  is,  with  thumb  and  finger  of  left  hand  to  seize  the 
neck  so  that  the  hook  may  be  passed  over  it,  or,  using  scissors,  hold  it 
until  the  division  is  made ;  it  may  also  be  held  by  the  ordinary  blunt 
hook  instead  of  by  the  fingers.  If  Braun's  hook  is  used,  after  placing 
it  over  the  neck,  strong  traction  with  partial  movements  of  rotation  is 
employed,  and  the  neck  is  quickly  severed.  The  body  is  then  readily 
extracted  in  most  cases  by  pulling  upon  one  of  the  arms ;  the  head  is 
withdrawn  by  traction  with  two  fingers  in  the  mouth,  or  by  the  forceps; 
in  some  instances  it  may  be  necessary  to  lessen  its  size. 

MELOTOMY.  It  may  happen'  that  an  upper  or  lower  limb  is  in  the 
vagina,2  and  so  greatly  swelled  that  manipulations  upon  the  body  of 
the  child  are  impossible  in  consequence  of  the  obstruction  ;  the  child 
being  dead,  the  member  is  amputated  by  the  scissors  of  Dubois. 

SPONDYLOTOMY.  This  is  the  name  given  to  division  of  the  vertebral 
column  at  some  other  point  than  the  neck.  It  may  be  done  with  the 
scissors  of  Dubois. 

1  This  method  of  decollation  has  been  repeatedly  done  in  practice,  more  especially  in  France ; 
I  have  been  in  the  habit  for  some  years  of  illustrating  it  before  my  class  at  Jefferson  Medical  Col- 
lege, using  a  full-grown  foetus  and  Bodin's  obstetric  manikin. 

2  Lomer,  op.  cit.,  tells  of  an  obstetrician  who  called  to  a  case  of  labor  in  which  he  found  the 
shoulder  wedged  in  the  pelvis,  the  arm  prolapsed,  and  believing  the  child  dead,  performed  exar- 
ticulation  of  the  arm:  the  child  was  born  living,  and  continuing  to  live,  when  he  was  twenty- 
one  years  old  sought  damages  from  the  operator ! 


640  THE  PATHOLOGY  OF  LABOR. 

EVISCERATION.  This  is  chiefly  resorted  to  in  those  cases  in  which 
an  impacted  shoulder  presentation  prevents  access  to  the  neck.  Again, 
the  scissors  of  Dubois,  or  a  similar  instrument,  will  be  the  most  useful 
in  opening  the  chest ;  after  the  contents  are  in  part  removed,  an  effort 
is  made  to  deliver  the  foetus,  of  course  doubled  upon  itself,  by  the 
crotchet  or  the  blunt  hook. 

After  embryotomy  not  only  the  external  sexual  organs  and  the 
vagina,  but  also  the  uterine  cavity  must  be  disinfected.  For  this  pur- 
pose a  solution  of  lysol  1  to  1|  per  cent,  may  be  employed  ;  a  corrosive 
sublimate  solution  will  not  be  used,  at  least  for  irrigating  the  uterus. 
So,  too,  the  utmost  care  must  be  taken  subsequently  to  guard  against 
infection. 

Winckel,  in  3500  labors,  performed  embryotomy  in  16,  or  only  0.46 
per  cent.,  and  two  mothers  died;  the  mortality,  therefore,  was  12.5  per 
cent.  Zeitlmann1  records  121  cases  of  craniotomy  at  Dresden,  1883— 
1892,  with  15  deaths,  12  of  these  occurring  outside  the  Klinik ;  more 
than  one-half  of  the  women  who  had  been  operated  upon  were  free  from 
fever,  and  with  three-fourths  the  lying-in  was  of  normal  duration. 

It  is  of  interest  to  state  that  craniotomy  was  done  upon  the  living  child  in  14 
cases,  in  5  on  account  of  threatened  uterine  rupture,  4  on  account  of  eclampsia, 
and  in  1  in  consequence  of  uterine  tympanites,  and  in  the  rest  for  other  dangers 
of  the  mother. 

1  Jahresbericht  uber  die  Fortschritte  auf  dem  Gebiete  der  Geburtshilfe  und  Gynakologie,  1894. 


SECTION   III. 
THE  PATHOLOGY  OF  THE  PUERPERAL  STATE, 


CHAPTER    XV. 

INTRODUCTORY.  The  diseases  here  considered  will  be  chiefly  those 
connected  with  the  puerperal  condition,  only  a  few  of  such  as  acci- 
dentally occur  being  referred  to ;  there  will  be  presented,  too,  the  subject 
of  sudden  death  in  or  after  labor,  and  also  some  of  the  diseases  of  the 
newborn,  in  addition  to  those  treated  on  pages  353,  354,  358. 

DISEASES  or  THE  BREAST.  The  breast  is  a  compound  organ,  one 
part  being  for  the  secretion  of  milk  and  the  other  for  its  discharge.  The 
tissues  covering  the  gland,  and  interposed  between  its  constituent  parts, 
and  connecting  it  with  the  chest  may  be  called  adventitious. 

DISEASES  OF  THE  NIPPLE.  Fissures  and  ulcers  of  the  nipple  are 
not  infrequent.  They  occur  oftener  in  primiparas  and  in  blondes. 
Among  the  causes. are  want  of  proper  care  in  the  latter  part  of  preg- 
nancy, failure  of  cleanliness,  difficult  extraction  of  the  milk,  either  from 
the  form  of  the  nipple  or  the  weakness  of  the  child,  so  that  each  nurs- 
ing is  prolonged,  and  the  skin  of  the  nipple  softened  so  that  the  epi- 
dermis is  in  places  detached  ;  or,  again,  the  robust  child,  by  its  violent 
sucking,  may  cause  mechanical  injury — it  has  been  said  that  some  in- 
fants have  "  murderous  mouths  " — and  later  in  lactation  the  infant  may 
bite  or  bruise  the  nipple.  From  an  ulcerated  and  fissured  surface  blood 
may  escape  when  the  infant  nurses,  and  be  swallowed  with  the  milk,  so 
that  in  case  blood  appears  in  the  stools  or  in  the  vomited  matter  of  the 
child,  this  possible  source  should  be  considered.  In  addition  to  the 
suffering  the  mother  has  when  the  child  is  put  to  the  breast,  the  possible 
suspension  of  lactation,  temporary  or  permanent,  and  the  mammary 
inflammation  which  may  result  from  disease  germs  entering  through 
these  fissures  or  ulcers,  their  prevention,  and,  if  they  do  occur,  their 
prompt  cure,  are  most  important. 

The  prophylaxis  in  pregnancy,  believed  by  the  writer  most  useful, 
has  been  given  on  page  221.  To  this  may  be  added,  that  Ahlfeld  di- 
rects the  daily  application  to  the  nipple  in  the  last  weeks  of  pregnancy 
of  equal  parts  of  tincture  of  galls  and  water,  or  one  of  the  former  to 
two  of  the  latter. 

So,  too,  on  pages  349  and  350  the  prophylaxis  after  lactation  begins, 
and  some  of  the  methods  of  treating  diseased  nipples  are  presented.  Kalten- 
bach  advised,  if  fissure  of  the  nipples  appeared,  disinfecting  them  with  a 

41 


642      THE  PATHOLOGY  OF  THE  PUERPERAL  STATE. 

two  and  one-half  per  cent,  solution  of  carbolic  acid,  and  covering  them 
with  sterilized  gauze ;  he  also  recommended,  if  nursing  were  painful,  the 
use  of  the  glass  nipple-shield,  and  commended  the  double-aspirating 
shield  of  Auvard. 

FIG.  266. 


AUVARD'S  DOUBLE-ASPIRATING  NIPPLE-SHIELD. 

The  shorter  tube  is  used  by  the  infant,  and  the  longer  by  the  mother 
or  nurse ;  suction  on  the  part  of  either  of  the  latter  facilitates  the  escape 
of  the  milk,  so  that  but  little  effort  on  the  part  of  the  former  is  neces- 
sary, and  the  time  of  nursing  is  shortened.  Ahlfeld  commends  the  ap- 
plication of  ice  in  the  intervals  between  nursing.  In  some  cases  the 
suspension  of  nursing  from  the  affected  nipple  for  several  days  will  be 
necessary  in  order  that  it  may  heal. 

MASTITIS.  This  is,  after  fissures  of  the  nipple,  the  most  frequent  of 
puerperal  mammary  diseases ;  it  is  caused  by  bacteria.  About  6  per 
cent,  of  nursing  women  suffer  from  it.  Three  varieties  of  the  disease 
are  recognized.  1.  Simple  phlegmon,  or  inflammation  of  the  connec- 
tive tissue,  the  origin  being  in  the  infection  from  fissures  or  ulcers. 
2.  Inflammation  of  the  glandular  portion,  the  infecting  agents  entering 
through  the  milk  ducts.  3.  In  exceptional  cases  the  breasts  are  the 
seat  of  metastatic  abscesses  arising  in  the  course  of  general  infection. 

In  very  rare  instances  the  first  form  of  inflammation  may  involve  the  connec- 
tive tissue  posterior  to  the  gland,  and  result  in  the  formation  of  a  retro-mam- 
mary abscess. 

Inflammation  of  the  connective  tissue,  called  also  interstitial  mastitis, 
is  much  the  most  frequent  form  of  the  disease.  The  streptococcus 
pyogenes  is  the  cause,  more  seldom  the  staphylococcus,  of  this  form  of 
inflammation,  while  the  latter  is  present  in  parenchymatous  inflamma- 
tion. 

So  far  as  the  entrance  of  infectious  organisms  through  the  milk-ducts 
is  concerned,  several  observers  have  found  them  in  the  first  drops  of 
milk,  and  it  is  not  easy  to  understand  why  they  are  in  the  vast  majority 
of  cases  harmless  and  in  a  few  most  mischievous. 

The  majority  of  cases  of  mastitis  begin  the  second  week  after  labor ; 


MASTITIS.  643 

a  chill  occurs  and  is  followed  by  fever ;  if  the  fever  continues  longer 
than  two  days,  according  to  Olshausen,  suppuration  may  be  expected. 
Kronig  has  recently  stated1  that  in  20  per  cent,  of  cases  of  fever  in 
women  after  labor  inflammation  of  the  nipple  and  of  the  gland  is  the 
cause. 

The  retention  of  milk  in  the  breast  is  not  the  cause  of  inflammation,  as  pop- 
ularly believed,  and  therefore  the  continued  efforts  to  draw  the  milk  out,  efforts 
that  frequently  are  by  no  means  gentle,  have  not  the  supposed  benefit  given 
them.  The  view  generally  accepted  by  obstetric  authorities  is  that  milk  stasis 
is  not  the  cause  of  mastitis,  or,  epitomizing  the  truth,  one  might  say  milk  does 
not  make  matter. 

It  is  to  be  noted  that  interstitial  inflammation  may  extend  to  the 
glandular  structure,  and  so  the  latter  may  also  involve  the  connective 
tissue. 

Kehrer2  states  in  reference  to  the  relative  frequency  of  inflamma- 
tion of  the  breasts,  the  statistics  of  Hennig,  McClintock,  Winckel, 
and  Bryant  show  that  in  598  cases  the  right  breast  was  affected  in  290, 
or  48.54  per  cent. ;  the  left  breast  in  225,  or  37.6  per  cent.,  and  both 
breasts  in  83,  or  13.8  per  cent. 

He  also  gives  the  following  figure,  showing  the  relative  frequency 
with  which  different  lobules  are  affected  : 


E     £^ 


34.4 
L 

ILLUSTRATING  PARTS  OF  BREAST  INFLAMED.    RELATIVE  FREQUENCY. 
u,  upper  part  of  breast ;  L,  lower ;  E,  external,  and  i,  internal. 

The  breast  is  represented  as  divided  into  octants,  and  there  can  be 
read  on  the  outside  of  the  external  circle  the  per  cent,  of  each  of  these 
parts  that  is  inflamed. 

Treatment.  If  mastitis  occurs,  the  child  should  not  be  permitted 
to  nurse  from  the  affected  breast,  though  it  continues  to  use  the  other. 
The  breast  is  supported  by  a  suitable  bandage.  Winckel  advises  the 
application  of  compresses  of  lead-water  day  and  night ;  a  saline  may 
be  given,  and  the  patient  restrict  the  quantity  of  liquid  taken.  Dr. 
Bartholow  recommends  enveloping  the  breast  in  lint  wet  with  a  solu- 
tion of  atropine  in  rose-water,  four  grains  to  the  ounce;  he  adds  to  the 

1  Monatsschrift  fur  GeburtshUlfe  und  Gynaekologie,  June,  1895. 

2  MUller's  Handbuch,  Band  ill. 


644      THE  PATHOLOGY  OF  THE  PUERPERAL  STATE. 

advice  the  caution  that  as  systemic  effects  may  be  produced  by  such  an 
application,  the  removal  of  it  should  the  pupils  dilate  and  the  mouth 
become  dry. 

Dr.  Hiram  Corson1  strongly  advocated  treating  mammary  inflamma- 
tion by  applications  of  ice,  stating  that  during  twenty-seven  years  in 
which  he  has  employed  it  he  has  failed  in  no  instance  to  disperse  the 
inflammation,  if  suppuration  had  not  already  occurred,  and  at  the  same 
time  brought  comfort  to  the  patient.  He  stated  :  "  There  is  no  better 
way  to  apply  the  ice  than  to  put  it  into  a  bladder  with  just  enough 
water  to  float  it,  or  just  to  form  a  water  cushion,  that  will  fit  the  in- 
flamed part  nicely.  It  is  not  necessary  to  put  two  thicknesses  of  muslin 
between  the  bladder  and  the  breast;  it  is  not  too  cold  without  any,  but 
a  single  thickness  is  useful  to  keep  the  bladder  in  place  more  readily.'1 
Now  a  rubber  bag  would  be  used  rather  than  the  bladder  advised  by 
Dr.  Corson. 

Both  Kaltenbach  and  Ahlfeld  recommend  the  ice  treatment  of  mas- 
titis. This  is  certainly  a  most  important  testimony  to  the  value  of  Dr. 
Corson's  plan. 

Dr.  P.  A.  Harris2  advises  treating  mastitis  by  bandaging  and  rest.  The  plan 
he  pursues  is  thus  stated  :  ''  Having  discovered  the  existence  of  an  inflamma- 
tory movement  in  the  breast,  of  any  grade  of  severity,  or  at  any  stage  of  ad- 
vancement, short  of  the  formation  of  an  abscess,  I  should  at  once  interdict 
nursing,  friction,  pumping,  the  application  of  fomentations,  in  fact,  every  local 
measure  excepting  such  as  are  calculated  to  secure  complete  rest  for  the  gland; 
rest  from  passive  motion,  rest  from  secretion,  and  rest  from  pain.  All  these 
conditions  can,  in  a  great  degree,  be  immediately  secured  for  the  patient.  Pro- 
cure at  once  a  roll  of  soft  cotton-wool,  cotton  batting,  a  plain  roller-bandage  at 
least  twenty  yards  long  and  two  or  two  and  a  quarter  inches  wide;  also  eighteen 
large  safety  pins.  The  breast  is  first  covered  with  a  layer  of  cotton-wool,  and 
the  bandage  so  applied  as  to  lift  up  and  compress  the  affected  organ.  The 
patient  should  be  seen  daily,  and  the  bandage  reapplied  until  the  crisis  has 
passed ;  this  time  varying  from  one  to  several  days." 

If  suppuration  occurs,  free  opening  of  the  abscess  and  drainage,  an- 
tiseptics being  employed.  The  incision  must  be  made  in  a  radiating 
direction,  so  as  to  avoid  cutting  one  or  more  of  the  milk-ducts,  an  acci- 
dent which  might  happen  were  it  transverse. 

Many  years  since  I  first  tried,  with  very  satisfactory  results,  the  method  of  treat- 
ing mammary  abscesses  recommended  by  Dr.  Foster.  It  was  referred  to  by  the 
late  Dr.  Gross  in  the  second  edition  of  his  Surgery,  1862,  as  having  been  advised 
"  within  the  last  few  years."  While  especially  applicable  to  neglected  mam- 
mary abscesses  in  which  the  pus  has  burrowed,  and  sinuses  been  formed,  it  may 
be  used  successfully  in  others  in  which  the  closure  of  the  abscess  cavity  delays. 
It  consists  in  the  application  to  the  breast  of  a  large,  compressed  sponge ;  of 
course,  the  sponge  must  be  thoroughly  cleansed  and  dried  ;  next  it  is  compressed 
by  means  of  a  heavy  weight,  or  in  a  book-press,  and  then  applied  to  the  breast ; 
it  must  be  large  enough  to  cover  it  completely,  only  one  or  two  thicknesses  of 
patent  lint  placed  next  the  skin,  and  the  sponge  secured  in  place  by  a  firmly 
applied  bandage.  Next,  the  sponge  is  wet  with  tepid  water  through  the  band- 
age, and  consequently  swells,  producing  uniform  compression,  so  that  abscess 
contents  are  squeezed  out  and  abscess  walls  brought  in  contact.  The  sponge  is 
changed  once  in  twenty-four  hours. 

i  American  Journal  of  Obstetrics,  1881.  Ibid.,  1885. 


SCARLATINA.  645 

Of  course,  using  this  method  to-day,  the  sponge  would  be  made  completely 
aseptic,  the  water  used  for  applying  through  the  bandage  to  it  would  contain  an 
antiseptic,  and  probably  the  lint  would  be  replaced  by  antiseptic  gauze. 

MALARIAL  FEVER.  This  disease  may  occur  in  the  puerperal  period, 
but  it  is  not  frequeut.  The  subjects  have,  as  a  rule,  had  attacks  of 
intermittent,  or  remittent,  shortly  before  or  during  pregnancy.  More- 
over, they  present  the  history  of  exposure.  It  is  possible  that  labor 
with  its  exhaustion  may  cause  manifestation  of  the  poison  that  has  been 
lying  dormant  in  the  system  It  is  very  important  that  the  obstetrician 
should  not  make  a  mistake,  attributing  to  malaria  one  of  the  forms  of 
puerperal  infection,  thereby  losing  precious  time  and  lulling  himself 
and  the  patient  in  false  belief  of  no  danger.  Malarial  attacks  are 
regularly  and  distinctly  intermittent  or  remittent.  The  malarial  tongue, 
first  described  by  Osborn,  in  1851, 1  and  again  in  1869,2  may  help  in 
the  diagnosis. 

"  It  will  be  noticed  that  the  middle  of  the  tongue  is  heavily  coated  with  dirty 
fur,  which  thins  off  toward  the  point,  where  the  color  of  the  papillae  can  be  seen 
pressing  through  the  attenuated  coating,  whilst  on  the  sides  of  the  fur  there 
are  clean,  smooth,  depressed  margins,  having  a  bright  red  color.  The  sides  or 
edges  of  the  tongue  are  flattened,  pinkish,  and  traversed  by  sharp  lines,  creat- 
ing the  impression  to  the  eye  of  the  observer  that  the  parts  are  crenated,  striated, 
corrugated,  puckered,  or  crimpled — either  term  having  a  shade  of  appropriate- 
ness— but  which,  upon  close  inspection,  will  be  found  situated  in  the  substance 
of  the  tongue,  leaving  the  mucous  membrane  even  and  smooth  to  both  sight 
and  touch."  "  The  transverse  lines  are  too  numerous  and  near  to  each  other  to 
attribute  them  to  pressure  by  the  teeth." 

Finally,  the  promptness  with  which  quinine  arrests  the  disease  con- 
firms the  diagnosis  :  cum  ostendit  morbum. 

It  seem  to  me  probable  that  in  some  cases  at  least,  the  disease  called  Weid* 
incorrectly  Weed,  was  really  intermittent  malarial  fever ;  this  opinion  rests 
upon  the  description  of  the  disease  and  upon  its  successful  treatment  by  anti- 
periodics. 

SCARLATINA.  This  disease,  though  not  frequent  in  the  lying-in,  is 
probably  oftener  observed  than  in  pregnancy,  and  a  prolonged  period 
of  incubation  has  been  by  some  thought  to  explain  the  fact. 

Before  the  use  of  antiseptics  scarlet  fever  in  puerperal ity  was  very 
fatal,  but  now  the  great  majority  recover ;  Meyer,  for  example,  in  the 
Copenhagen  Maternity,  had  twenty-one  cases  with  only  three  deaths. 
Nevertheless  it  is  probable  that  scarlet  fever,  more  than  any  other  of 
the  exanthematous  diseases,  creates  a  liability  to  septic  infection.  .  ^ 

.    i  Western  Journal  of  Medicine  and  Surgery,  August,  1851.       "•?     "~ 

2  Transactions  of  the  American  Medical  Association,  vol.  xx. 

3  An  American  obstetrician  a  few  years  since,  referring  to  the  word  "  weed,"  states,  "  The  dic- 
tionaries of  the  English  language  I  have  examined  do  not  contain  the  word  in  the  sense  of  a 
disease."    American  System  of  Obstetrics,  vol.  ii. 

Ephemeral  Fever,  or  Weid,  has  been  described  by  several  obstetric  writers ;  for  example, 
Burns.  Ramsbotham,  and  Churchill. 

"  Weid.  a  kind  of  fever  to  which  women  in  childbed,  or  nurses,  are  subject.  German  weide, 
or  weite,  corresponds  to  French  accdbU,  as  signifying  that  one  is  oppressed  with  disease."  Jamie- 
son's  Etymological  Dictionary  of  the  Scottish  Language.  Edinburgh,  1818. 

In  Ogilvie's  dictionary  the  following  definition  is  given:  "A  general  name  for  any  sudden 
illness  from  cold  or  relapse,  usually  accompanied  by  febrile  symptoms,  taken  by  females  after 
confinement  or  during  nursing." 

Ramsbotham  remarks  that  Scott,  in  his  "  Bride  of  Lammermoor,"  makes  one  of  the  women 
speak  of  a  child  as  having  the  "  weid ; "  so  that  it  seems  to  be  applied  to  children  as  well  as  puer- 
peral women. 


646  THE  PATHOLOGY  OF  THE  PUERPERAL  STATE. 

Antisepsis,  isolation,  milk  diet,  in  anticipation  of  possible  renal  com- 
plication, and,  if  the  temperature  be  high,  the  cold  bath  constitute  the 
most  generally  accepted  treatment.  For  intestinal  antisepsis  beta- 
naphthol  has  been  recommended1  by  Tournery  and  Durand. 

ERYSIPELAS.  If  erysipelas  originates  in  the  face  or  upper  part  of 
the  body  in  the  puerpera,  it  frequently  runs  its  course  without  danger 
and  without  interference  with  normal  involution  of  the  sexual  organs. 
In  some  cases  the  disease  has  begun  in  a  fissure  or  other  injury  of 
the  nipple.  In  five-sevenths  of  the  cases,  however,  the  disease  starts 
from  the  external  genital  organs,  and  the  nates,  according  to  Winckel. 
So,  too,  he  states  that  primiparae  are  more  liable  to  erysipelas  than 
multipart,  three  or  four  of  the  former  to  one  of  the  latter.  He  teaches 
that  the  poison  of  erysipelas  may  cause  one  of  the  grave  forms  of  puer- 
peral fever. 

Kaltenbach  made  the  statement  that  in  general  one  was  inclined,  both  by 
clinical  as  well  as  bacteriological  investigations,  to  believe  that  the  streptococcus 
erysipelatis  and  the  streptococcus  pyogenes  are  identical. 

Bumm  (Hlstological  Researches  upon  Endometritis),  after  referring  to  the  fact 
that  infectious  germs  proceeding  from  the  endometrium,  following  the  fine 
lymphatics  between  the  tissue  elements,  penetrate  the  uterine  wall,  and  through 
this  finally  reach  the  peritoneum,  causing  a  mortal  peritonitis,  adds  :  "  It  can- 
not be  doubted  that  this  mode  of  propagation  corresponds  to  that  which  is 
observed  in  erysipelas  of  the  skin,  and  I  am  convinced,  by  these  histological 
demonstrations,  that  the  denomination,  internal  erysipelas,  proposed  by  Winckel , 
is  justified  by  this  and  similar  cases,  although  the  distinction  between  the 
streptococcus  of  erysipelas  and  the  streptococcus  pyogenes  is  to-day  no  longer 
available." 

In  fourteen  fatal  cases  of  puerperal  erysipelas  observed  by  Winckel 
the  causes  of  death,  with  the  exception  of  one  in  which  death  re- 
sulted from  meningitis,  were  colpitis,  endometritis,  metro-lymphangitis, 
parametritis,  pleuritis,  and  pneumonia. 

In  regard  to  the  treatment  of  puerperal  erysipelas,  it  will  not  differ 
from  that  required  by  the  disease  under  other  conditions.  It  is  impor- 
tant that  the  infant  be  cared  for  by  some  one  else  than  the  nurse  having 
charge  of  the  mother,  and  that  it  be  taken  to  another  room,  lest  it 
should  become  infected,  the  infection  usually  appearing  first  at  the 
navel. 

PUERPERAL  TETANUS.  This  may  occur  after  abortion,  or  after 
labor  at  term,  but  it  is  a  »-are  disease.  Sir  James  Y.  Simpson,  in  1854, 
collected  24  cases,  and  Vinay,  in  1891,  106 — 47  following  abortion 
and  61  labor.  As  showing  the  contagious  character  of  tetanus,  the  case 
reported  by  Ammon,  of  Munich,  is  important :  He  had  treated  a 
laborer  suffering  with  traumatic  tetanus  in  consequence  of  a  wound  of 
the  hand  ;  the  day  after  his  death  Aramon  attended  a  case  of  labor,  and 
artificial  removal  of  the  placenta  was  necessary ;  tetanus  appeared  the 
ninth  day,  and  was  fatal  in  five  days.  Henricius,  quoted  by  Vinay, 
states  that  a  midwife,  making  a  vaginal  examination  of  a  recently  de- 
livered woman,  just  after  she  had  dressed  the  umbilical  wound  of  an 
infant  suffering  with  trismus,  communicated  tetanus  to  her. 

1  La  Rougeole  et  la  Scarlatina  dans  la  Grossesse  et  les  suites  de  couches.    Paris,  1891. 


MKXTAL  DISORDERS.  (547 

In  52  of  Vinay's  cases  there  was  some  obstetrical  intervention,  the 
chief  being  the  artificial  removal  of  the  placenta  and  the  application  of 
a  tampon.  As  it  has  occurred  after  ovariotomy,1  in  1877  I  collected 
13  cases,  one  of  them  my  own,  it  lias  also  followed  gastro-hysterotorny 
and  gastro-hysterectomy. 

The  disease  is  more  frequent  in  tropical  countries.  Wallace2  saw  at 
Calcutta  in  ten  years  23  cases,  and  Pedley3  states  that  it  is  a  compara- 
tively frequent  cause  of  death  in  childbed  among  the  Burmese.  Prob- 
ably want  of  cleanliness  is  a  more  important  factor  than  climate  in  the 
production  of  the  disease. 

The  essential  cause  is  a  bacillus  discovered  by  Nicolaier  in  1885,  and 
which  is  found  in  the  soil,  especially  in  that  containing  dung  of  the 
horse,  as  well  as  that  of  other  herbivora. 

In  44  cases  in  which  the  advent  of  the  disease  was  recorded  the  time 
varied  from  the  first  to  the  sixteenth  day  after  delivery.  (Vinay.) 

Irvin,4  of  Louisville,  Ky.,  has  reported  a  case  of  tetanus  occurring  the  eleventh 
day  after  delivery  at  term  that  recovered  under  supporting  treatment,  half-grain 
doses  of  morphine,  pro  re  nata,  and  chloral  in  sufficient  quantity  to  procure 
sleep.  Mosher5  has  recently  published  a  fatal  case  following  abortion.  While 
revising  these  pages  I  had  a  letter  from  Drs.  Hopkins,  father  and  son,  of  Milton, 
Del.,  narrating  a  fatal  case  of  tetanus  under  their  charge  June,  1895.  The 
patient  was  attended  by  a  midwife,  the  labor  natural,  and  convalescence 
apparently  proceeded  normally ;  an  anomaly  was  the  absence  of  lochial  flow 
after  the  first  day.  Tetanus  appeared  on  the  seventh  day  after  labor,  and  death 
occurred  on  the  ninth.  At  no  time  was  there  a  chill,  and  the  patient  had  no 
offensive  flow  and  no  fever.  The  treatment  was  morphine,  chloral,  and  chloro- 
form inhalation. 

The  mortality  of  the  disease  is  given  by  Vinay  as  88.8  per  cent. 

But  little  can  be  said  as  to  the  treatment.  Prevention  is  more  hope- 
ful than  cure.  The  vitality  of  the  bacillus  of  Nicolaier  is  very  great, 
resisting  for  hours  the  action  of  corrosive  sublimate  solution,  and  the 
obstetrician  who  dresses  the  wound  of  infant  or  adult  suffering  from 
tetanus  ought  to  refrain  from  attending  a  case  of  labor.  Mechanical 
disinfection  is  more  important  than  chemical,  and  to  this  end  the  free 
use  of  the  nail-brush  and  the  employment  of  green  soap  and  sand  with 
hot  water  are  to  be  commended.  But  little  can  be  expected  from 
acting  upon  the  uterine  wound  by  antiseptic  injections ;  while  they 
may  be  tried,  it  is  important  to  avoid  all  violence.  Chloral,  morphine, 
chloroform,  curare,  and  other  remedies  that  have  been  advised  may  be 
used,  but  probably  without  material  benefit;  the  most  promising  treat- 
ment will  be  an  injection  of  serum  from  an  animal  that  has  been  made 
immune  to  tetanus ;  this  method,  recommended  by  various  writers,  has, 
according  to  Vinay,  alleviated  the  symptoms  in  some  cases,  and  in  others 
seems  to  have  effected  a  cure. 

MENTAL  DISORDERS.  Under  the  name  puerperal  insanity,  or  puer- 
peral psychoses,  disorders  of  the  mind  occurring  in  pregnancy,  the 
puerperal  state,  or  in  lactation, have  been  included.  Probably  such  dis- 

1  Transactions  of  the  American  Gynecological  Society,  vol.  ii. 

2  M tiller's  Geburtshtilfe. 

3  Transactions  of  the  London  Obstetrical  Society,  vol.  xxix. 

4  New  York  Medical  Record,  1892. 

s  Kansas  City  Medical  Index,  1895. 


648  THE  PATHOLOGY  OF  THE  PUERPERAL  STATE. 

orders  occur  in  2  of  1000  labors.  Approximately  one-twelfth  of  all 
cases  of  insanity  in  women  are  puerperal.1  Insanity  appearing  in  the 
puerperium  is  the  most  frequent,  and  in  pregnancy  the  rarest. 

The  causes  chiefly  are  heredity,  eclampsia,  hysteria,  chorea,  renal  dis- 
ease, infectious  puerperal  maladies,  epilepsy,  anaemia,  exhaustion  from 
hemorrhage  or  from  lactation  :  to  these  causes  may  be  added  toxaemia. 
It  is  stated  that  moral  causes  are  more  frequently  observed  in  the  higher, 
and  physical  causes  in  the  lower,  classes  of  society. 

MELANCHOLIA,  MANIA,  AND  MONOMANIA  are  the  chief  forms. 
Ripping,  as  quoted  by  Kehrer,2  gives  the  following  statement  as  to  com- 
binations of  mental  disorders  observed  by  him  in  a  hospital  for  the  in- 
sane. These  combinations  are  presented  in  a  decreasing  frequency  :  1. 
Primary  melancholia,  lasting  weeks  and  months,  then  mania.  2.  First 
melancholia,  then  monomania  with  ideas  of  persecution  and  of  exalta- 
tion. 3.  Mania  with  following  confusional  insanity.  4.  First  coufu- 
sional  insanity,  then  melancholia. 

Ripping' s  statistics  show  that  of  100  cases  of  puerperal  insanity  16. 4 
per  cent,  occurred  in  pregnancy,  50.6  per  cent,  in  childbed,  and  33  per 
cent,  in  lactation. 

INSANITY  DURING  PREGNANCY.  It  is  not  uncommon  for  a  preg- 
nant woman,  especially  if  it  be  her  first  experience,  to  be  at  times  pro- 
foundly depressed,  and  to  be  apprehensive  of  the  most  grave  results 
from  her  condition.  So,  too,  some  pregnant  women  may  be  so  vexed, 
so  tormented  at  the  prospect  of  being  mothers,  that  they  insist  they 
"will  go  crazy,"  threaten  to  commit  suicide  even,  hoping  that  the  phy- 
sician may  be  induced  to  rid  them  of  their  hated  burden.  But  in 
neither  of  the  cases  presented  is  there  actual  insanity.  The  insanity  of 
pregnancy  is  usually  that  form  known  as  melancholia.  The  earlier  in 
the  pregnancy  the  disease  appears,  the  more  hopeful  the  prognosis. 
When  mania  is  associated  the  condition  is  much  more  grave ;  the 
severity  of  the  attack  is  also  unfavorable.  In  some  cases  attempts  at 
suicide  may  be  made.3  In  the  treatment  care  must  be  given  to  remove 
all  sources  of  disquiet  and  worry  from  the  patient;  in  some  instances 
a  complete  change  of  scene  and  circumstances  is  advisable,  even  placing 
her  in  a  hospital  for  the  insane ;  attention  must  be  given  to  nutrition 
and  to  securing  regular  and  sufficient  rest. 

INSANITY  IN  THE  PUERPERAL  STATE.  It  sometimes  happens 
during  labor  that,  under  severe  suffering,  a  woman  has  temporary  de- 
lirium, and  there  may  be  momentary  irresponsibility  for  words  or  acts ; 
but  when  the  labor  is  over,  the  cloud  and  the  storm  pass  away,  leaving 
the  intellect  perfectly  clear ;  the  condition  is  too  transient  to  be  called 
insanity,  or  to  demand  special  treatment,  save  the  mitigation  of  the  suf- 
fering by  appropriate  means.  Mania  is  the  most  frequent  form  of 

1  In  examining  the  Report  of  the  Pennsylvania  Hospital  for  the  Insane,  1890,  I  find  that  includ- 
ing those  cases  of  mental  derangement  attributed  to  the  puerperal  state  and  to  prolonged  lactation, 
puerperal  insanity  embraced  15  per  cent,  of  insane  women. 

*  Muller's  Handbuch. 

3  Thorburn,  Lancet,  June  29,  1879,  reports  a  case  of  suicidal  mania  in  a  woman  four  months 
pregnant ;  he  induced  abortion — "  premature  labor,"  he  calls  it — and  the  patient  in  a  very  short 
time  was  sane.  It  is  doubtful  whether  the  treatment  would  meet  general  professional  indorse- 
ment—at least  it  is  to  be  feared  if  abortion  were  commonly  recognized  as  the  remedy,  there  would 
be  many  cases  of  feigned  insanity. 


THE  INSANITY  OF  LACTATION.  049 

puerperal  insanity.  Hallucinations1  of  sight  and  hearing,  suspicion, 
even  fear  or  hatred,  of  those  hitherto  loved  and  trusted,  indiiference  or 
absolute  aversion  to  her  child  occur.  The  disease  in  almost  all  cases 
appears  in  the  first  week  of  the  puerperium,  "within  ten  or  twelve  days 
after  confinement,"  according  to  Weber.  Melancholia,  on  the  other 
hand,  is  later  in  its  appearance,  and  if  recovery  occurs  it  is  after  a  much 
longer  period  than  when  this  follows  mania. 

Etiology.  In  regard  to  the  causes  of  childbed  insanity,  Hoppe2  found 
in  his  own  statistics  56  per  cent,  in  which  heredity  was  a  factor,  and 
he  states  the  usual  proportion  is  35  per  cent.  So,  too,  primiparity 
was  a  cause  in  45  per  cent. ;  the  usual  proportion  of  authors  is  32  per 
cent.  Finally,  possible  infection  was  present  in  66  per  cent. 

Campbell  Clark3  has  insisted  especially  upon  infection  as  a  cause  of  puerperal 
psychoses:  "This  toxaemia  may  result  from  diminution,  modification,  or  even 
arrest  of  secretions  and  excretion  of  organism."  He  understands  thereby  mod- 
ification in  the  secretion  of  bile,  intestinal  fluids,  urine,  lochia,  and  septic  ab- 
sorption. There  may  be  a  new  or  accidental  intoxication — typhus  in  one  case, 
scarlatina  in  another,  alcohol  given  too  freely,  and  chloroform  in  the  lying-in  ; 
8  were  cases  of  well-marked  septic  infection.  An  important  fact  is  that  quite  a 
number  of  eclamptics  become  insane,  Lohlein  making  the  proportion  5.15  per 
cent,  and  Olshausen  6  per  cent. 

Idanhof,  of  Moscow,  from  a  study  of  53  cases  of  puerperal  insanity,  states* 
that  after  a  severe  hemorrhage  a  powerful  emotion  can  result  in  a  psychosis  if 
the  subject  is  predisposed  to  mental  disease,  and  remarks  that  it  is  indispensable 
during  the  puerperal  period  to  preserve  the  woman  from  sepsis  as  well  as  from 
mental  emotion. 

Prognosis.  The  prognosis  of  the  psychoses  of  childbed  is,  according 
to  Spiegelberg,  more  favorable  than  that  of  any  other  puerperal  form, 
.both  as  regards  the  duration  of  illness  and  as  regards  complete  mental 
and  physical  reeovery.  Restoration  in  the  majority  of  cases  takes  place 
within  six  months. 

Hoppe's  statistics  as  to  cases  of  puerperal  insanity  are :  50  per  cent, 
cured ;  9  per.  cent,  improved ;  5  per  cent,  died,  and  23  per  cent,  not 
cured. 

Treatment.  In  the  treatment  the  removal  of  all  exciting  condi- 
tions, attention  to  digestion,  quiet  of  body  and  of  mind,  improvement 
of  the  blood,  if  that  is  impoverished,  especially  by  the  administration  of 
iron,  regular  bathing,  the  securing  of  rest  by  chloral,  opium,  sulphonal 
are  the  essentials ;  several  commend  hyoscyamine,  and  Lloyd5  speaks 
favorably  of  paraldehyde  in  cases  of  even  acute  mania.  Of  course  if 
the  disease  does  not  readily  yield  to  treatment  at  home,  the  sooner  the 
patient  can  be  removed  to  an  asylum  the  better. 

THE  INSANITY  OF  LACTATION.  This  may  appear  six  or  seven 
weeks,  or  several  months  after  labor,  or  finally  a  few  days  after  ceasing 

1  The  poet's  picture  will  impress  this  more  strongly  : 

"  I  hear  a  voice  you  cannot  hear, 
Which  says  I  must  not  stay  ; 
I  see  a  hand  you  cannot  see, 
Which  beckons  me  away." 

2  Arch.  f.  Psychiatric,  1893. 

3  Journal  of  Medical  Science,  1887.    *  Annales  Medico-Psycologique,  1893. 
3  American  System  of  Obstetrics,  vol.  ii. 


650  THE  PATHOLOGY  OF  THE  PUERPERAL  STATE. 

to  nurse.  It  may  be  manifested  under  any  one  of  the  forms,  mania, 
monomania,  melancholia,  or  insanity  with  a  doubtful  form,  "  circular 
insanity,"  all  "  accompanied  with  hallucinations  and  impulsive  ideas, 
and  homicidal  or  infanticidal  tendencies. " 

The  prognosis  is  favorable,  most  cases  recovering  if  the  child  be 
weaned.  Marc6  saw  20  cured  out  of  26  ;  but  the  cure  may  be  slow,  and 
may  not  occur  for  several  months,  or  even  for  years  (Charpentier).  In 
case  the  disorder  follows  suspension  of  lactation,  cure  has  been  effected 
by  its  resumption. 

PAEALYSIS,  AND  NEURALGIA  OF  THE  LOWER  LIMBS.  These  dis- 
orders may  be  caused  by  direct  injury  in  labor,  and  are  more  frequent 
in  case  of  narrow  pelvis,  or  of  large,  hard  head ;  they  may  follow 
forceps  delivery,  especially  if  this  delivery,  rendered  necessary  possibly 
by  one  of  the  conditions  just  mentioned,  is  rapid  and  violent.  The 
pain  and  loss  of  motion  usually  disappear  in  a  few  days ;  but,  on  the 
other  hand,  may  last  for  weeks,  and  even  months.  Such  prolongation 
of  paresis  necessarily  causes  some  atrophy  of  the  muscles  involved. 

But  paresis  and  neuralgia  may  not  appear  until  several  days  or  even 
a  few  weeks  after  labor,  and  then  be  simultaneous  with  or  follow  puer- 
peral infection.  They  are  attributed  to  pressure  by  an  exudate  or  by 
the  contraction  of  cicatricial  tissue.  In  these  cases  neuralgic  is  more 
prominent  than  paretic  disorder.  Both  cease  by  the  absorption  of  the 
exudate  or  its  suppuration  and  discharge.  After  the  subsidence  of  the 
acute  stage,  pain  being  relieved  by  usual  means,  the  loss  of  power  is 
sought  to  be  prevented  or  cured  by  massage  and  by  electricity,  faradism 
being  employed  if  electric  contractility  has  not  been  lost ;  but  if  it  has, 
the  continuous  current.  The  left  limb  is  more  frequently  affected  than 
the  right. 


CHAPTER    XVI. 


PUERPERAL    FEVER. 

PUERPERAL  FEVER  is  probably  almost  coeval  with  the  race  and 
coextensive  with  the  habitation  of  man.  Hippocrates  described  cases 
of  the  disease;  it  has  been  observed  iu  all  lauds  from  Iceland  to  India 
— wherever  and  whenever  women  bring  forth  it  may  appear. 

While  it  has  been  especially  a  disease  of  lying-in  hospitals  and  of 
dense  populations,  it  has  likewise  occurred  in  private  practice  and  in 
thinly  settled  territories.  In  recent  years  the  use  of  antiseptics  has 
reversed  probably  the  relative  frequency  of  the  malady  in  hospitals  and 
in  private  practice.  The  liability  to  infection  belongs  to  every  puerpera, 
but  the  fact  of  infection  is  independent  of  her. 

It  may  be  defined  as  an  acute  disease  occurring  in  childbed,  in  quite 
exceptional  cases  manifested  in  labor,  produced  by  the  entrance  of  a 
poison  through  a  wound  of  the  genitals ;  the  disease  is  contagious,  and 
the  creation  of  the  poison  in  the  person  affected  is  impossible  without 
the  action  of  external  agents — in  other  words,  the  disease  is  hetero- 
genetic.  The  term  puerperal  fever  dates  from  the  beginning  of  the  last 
century,  and  in  recent  years  has  met  not  a  little  criticism  ;x  but  if  we 
do  not  understand  by  the  name  that  a  specific  fever  is  designated,  the 
chief  objections  to  its  use  fall,  and  the  difficulty  in  finding  a  suitable 
substitute  is  an  argument  for  retaining  the  term. 

Foremost  among  essential ists,  at  least  in  this  country,  was  the  late  Dr.  Fordyce 
Barker,  who  claimed  that  there  was  a  fever  peculiar  to  puerperal  women,  and, 
therefore,  appropriately  named  puerperal  fever,  that  the  symptoms  of  this  dis- 
ease were  essential,  and  not  the  consequence  of  any  local  lesions,  and  it  was  as 
much  a  distinct  disease  as  typhus,  typhoid,  or  relapsing  fever. 

This  faith  once  commonly  admitted  finds  few  adherents  to-day,  or  at  least 
they  restrict  essential  puerperal  fever  within  such  narrow  limits  that  the  faith 
becomes  a  rapidly  vanishing  quantity.  Grandin  remarks :  "  The  future,  we 
think,  will  testify  to  the  truth  of  Barker's  views  in  very  exceptional  instances ; 
that  is  to  say,  while  septicaemia  will  be  the  disease  in  nine  hundred  and  ninety- 
nine  cases,  iu  the  thousandth  the  disease  will  be  of  zymotic  origin."  When  an 
empire  is  content  with  one-thousandth  part  of  what  was  once  its  domain,  it  may 
be  safely  left  to  the  harmless  dream  of  possession  and  power. 

The  difficulty  in  finding  a  better  term  than  puerperal  fever  must  be  obvious ; 
therefore  it  seems  necessary  to  retain  this  term,  though  admitting  that  it  is  not 
unobjectionable. 

Cullingworth2  has  said  the  term  puerperal  fever  has  certain  unmistakable 
advantages.  "  Everyone  knows  what  is  meant  by  it ;  it  is  comprehensive,  and 
it  involves  no  theory  as  to  the  nature  of  the  disease." 

1  Pajot  has  said  that  the  designation  puerperal  fever  should  be  consigned  to  the  museum  of  the 
antiques.    Hervieux  declares  that  there  is  no  puerperal  fever  in  the  sense  ordinarily  attached  to 
the  word.    "The  admission  of  this  seductive  and  convenient  hypothesis  is  chaos,  it  is  return  to 
the  infancy  of  the  art,  it  is  the  negation  of  all  diagnostic  science,  the  obstacle  to  all  progress  in 
therapeutics  in  puerperal  maladies." 

2  A  Plea  for  the  More  General  Adoption  of  Antiseptics  in  Midwifery  Practice.    London,  1888. 


652  THE  PATHOLOGY  OF  THE  PUERPERAL  STATE. 

It  would  seera  unnecessary  at  this  day  to  state  that  puerperal  fever  is 
contagious.  Nevertheless  the  truth  is  so  important  there  is  no  danger 
of  emphasizing  it  too  strongly.  Many  an  American  practitioner  can 
remember  when  leading  obstetric  teachers  in  one  of  our  great  cities 
taught  the  opposite;  and  everyone  who  was  instructed  by  these  teachers 
was  fortunate  if  he  did  not  wait  to  learn  at  the  death-bed  of  a  puerpera 
who,  putting  her  supreme  trust  in  him,  perished  from  his  ignorance,  the 
utter  falsity  of  the  teaching. 

The  late  Dr.  Oliver  Wendell  Holmes,  in  a  paper  entitled  u  Puerperal 
Fever  as  a  Private  Pestilence,"  published  in  1843,  and  republished  in 
1855,  probably  did  more  than  any  other  American  physician  to  correct 
this  erroneous  teaching  and  to  convince  the  American  profession  of  the 
contagiousness  of  childbed  fever.1  Many  an  American  mother  owes  her 
life  to  the  striking  array  of  facts  he  so  clearly  presented  in  sustaining 
his  thesis ;  the  number  saved  would  have  been  still  greater  if  his  essay 
had  been  presented  to  every  medical  graduate  before  engaging  in  prac- 
tice. Among  the  rules  Dr.  Holmes  suggested  were  the  following : 

"  1.  A  physician  holding  himself  in  readiness  to  attend  cases  of  midwifery 
should  never  take  any  active  part  in  the  post-mortem  examination  of  cases  of 
puerperal  fever. 

"  2.  If  a  physician  is  present  at  such  autopsies,  he  should  use  thorough  ab- 
lution, change  every  article  of  dress,  and  allow  twenty-four  hours  or  more  to 
elapse  before  attending  to  any  case  of  midwifery.  It  may  be  well  to  extend  the 
same  caution  to  cases  of  simple  peritonitis. 

"  3.  Similar  precautions  should  be  taken  after  the  autopsy  or  surgical  treat- 
ment of  cases  of  erysipelas,  if  the  physician  is  obliged  to  unite  such  offices  with 
his  obstetrical  duties,  which  is  in  the  highest  degree  inexpedient. '' 

It  will  be  observed  that  in  part  of  the  prophylaxis  Dr.  Holmes  anticipated  the 
teaching  of  Semmelweis.2  But  it  is  not  alone  from  autopsies  of  women  who  died 
from  puerperal  fever  or  peritonitis,  nor  from  the  living  who  are  suffering  from 
the  former  disease  or  with  erysipelas  the  contagion  may  be  carried  to  the 

HIn  Dr.  Holmes's  essay  when  republished  some  additions  were  made,  and  in  these,  referring  to 
the  criticisms  made  by  a  Philadelphia  teacher  of  obstetrics,  he  thus  speaks  :  "  One  unpalatable 
expression,  I  suppose  the  laws  of  construction  oblige  me  to  appropriate  to  myself  as  my  reward  for 
a  certain  amount  of  labor  bestowed  on  the  investigation  of  a  very  important  question  of  evidence, 
and  a  statement  of  my  own  practical  conclusions.  I  take  no  offence  and  attempt  no  retort.  No 
man  makes  a  quarrel  with  me  over  the  counterpane  that  covers  a  mother  with  her  newborn  infant 
at  her  breast.  There  is  no  epithet  in  the  vocabulary  of  slight  and  sarcasm  that  can  reach  my  per- 
sonal sensibilities  in  such  a  controversy.  Only  just  so  far  as  a  disrespectful  phrase  may  turn  the 
student  aside  from  the  examination  of  the  evidence,  by  discrediting  or  dishonoring  the  witness, 
does  it  call  for  any  word  of  notice." 

To  this  I  add  an  extract  from  a  letter  written  me  in  1874  by  Dr.  Holmes.  I  had  sent  him  a 
pamphlet  containing  a  sad  personal  experience  as  to  the  contagiousness  of  puerperal  fever,  a 
doctrine  which  when  a  medical  student  I  was  taught  to  reject,  and  wrote  him  a  brief  note.  From 
his  reply,  occupying  nearly  four  pages,  I  take  the  following :  "  The  testimony  you  bear  to  the  sad 
fact  which  I  laid  before  the  public  so  many  years  confirms,  if  confirmation  were  needed,  the  thesis 
I  maintained.  It  is  thirty-one  years  since,  April,  1843,  in  the  '  N.  E.  Quarterly  Journal  of  Medicine 
and  Surgery,'  a  periodical  of  merit,  but  which  died  with  its  fourth  n  amber,  I  published  an  article 
which  I  considered  settled  the  point  of  the  communicability  of  puerperal  fever  from  one  patient  to 
another  by  the  accoucheur. 

"  Dr. and  Dr. attacked  my  position  in  a  way  which  made  me  ashamed,  both  talking  like 

class  declaimers  in  the  face  of  facts  which  people  of  common-sense  could  only  interpret  in  one  way. 
I  confess  that  I  declaimed  too,  but  I  only  fired  powder  after  firing  shot  and  shell.  I  have  been  sick 
of  the  name  of  '  Professor '  ever  since. 

"  Hundreds  of  lives  might  have  been  saved  if  they  had  enforced  the  disagreeable  truth  I  had 
made  plain  enough  for  those  who  would  not  shut  their  eyes." 

4  In  a  biographical  sketch  of  Semmelweis  by  Dr.  Herdegen,  American  Journal  of  Obstetrics,  1885, 
the  following  incident  is  related  :  "  A  martyr  to  the  new  doctrine  was  found  in  Michaells,  the  pro- 
fessor of  obstetrics  at  the  University  of  Kiel,  and  one  of  the  first  obstetricians  of  all  time,  whose 
work  on  the  '  Contracted  Pelvis '  is  now  considered  classical,  all  our  modern  views  on  the  mech- 
anism of  labor  being  founded  upon  it.  A  near  relation  of  his,  whom  he  had  attended  in  labor, 
died  of  puerperal  fever.  Convinced  of  the  correctness  of  Sammelweis's  idea,  and  certain  that  it 
was  he  who  brought  her  death  instead  of  help,  being  at  the  time  much  occupied  with  autopsies 
on  patients  dead  of  puerperal  fever,  he  laid  himself  on  the  railway  track  and  was  crushed  by  the 
tram." 


PUERPERAL  FEVER.  653 

puerpera.  Contact  with  corpses  in  autopsies  or  in  dissections  may  be  the  origin 
of  the  infection. 

In  the  very  interesting  sketch1  of  Semmelweis,  by  Winckel,  it  appears  that  S. 
was  first  led  to  recognize  an  important  source  of  puerperal  infection  by  the  fatal 
illness  of  Professor  Koletschka,  March,  1847,  of  the  University  of  Vienna,  who 
having  received  a  dissection  wound  had  double  pleuritis,  pericarditis,  peritonitis, 
meningitis,  and  a  day  before  his  death  there  was  a  metastasis  to  the  eye.  Sem- 
melweis concluded  that  there  was  an  identity  between  the  disease  and  that  of  which 
so  many  hundreds  of  puerperal  women  perished.  In  the  school  for  instruction 
in  practical  midwifery,  with  which  he  was  connected,  there  were  two  depart- 
ments, one  for  the  teaching  of  medical  students,  and  the  other  for  that  of  mid- 
wives;  in  the  former  the  mortality  was  11.4  per  cent.,  while  in  the  latter  it  was 
only  2.7  per  cent.  He  then  began,  May,  1847,  to  require  students  to  wash  their 
hands  in  chlorine  water  before  making  vaginal  examinations,  and  in  the  year 
1848  the  puerperal  mortality  was  reduced  to  1.27  per  cent. 

It  will  thus  be  seen  that  the  obstetrician  anticipated,  in  practical  antisepsis, 
Lister  and  Pasteur. 

Winckel  states  that  only  Lange,  in  Heidelberg,  and  Kugelmann,  in  Hannover, 
accepted  unconditionally  the  teaching  of  Semmelweis,  while  it  was  rejected  up 
to  1864  by  Hecker,  Siebold,  Spiegelberg,  Virchow,  and  many  others.  Winckel 
in  1861-62  was  assistant  under  Professor  E.  Martin  in  the  obstetric  department 
of  the  Royal  Frauenklinik  of  Berlin,  and  in  harmony  with  his  chief,  and  on 
the  ground  of  the  observations  of  Semmelweis  the  slightest  contact  with  cadavers 
and  autopsies  was  strictly  avoided. 

Semmelweis  died  in  1865,  of  blood-poisoning,  having  injured  his  finger  in  an 
operation  upon  a  newborn,  and  from  this  injury  there  was  a  metastatic  abscess 
between  the  muscles  of  the  chest  that  perforated  the  pleura,  and  pyopneumo- 
thorax  resulted. 

Another  important  fact  in  the  etiology  of  puerperal  fever  was  observed  by  the 
Vienna  obstetrician.  A  pregnant  woman  suffering  from  advanced  uterine  cancer 
was  in  the  ward.  The  precaution  which  had  been  for  some  time  used,  washing 
the  hands  in  a  solution  of  chloride  of  lime  before  making  a  digital  examination, 
was  neglected.  The  labor  was  prolonged  for  several  days.  As  the  case  was  very 
grave  and  rare,  the  students  were  eager  to  examine.  Fourteen  women  who  were 
delivered  in  the  interval,  and  who  consequently  had  been  "  touched  "  by  the 
pupils,  had  puerperal  fever  and  died.  With  the  exception  of  these  unfot  unate 
women  there  were  no  others  sick. 

Siredey  mentions  seeing  two  women  die  from  septicaemia  who  were  delivered 
in  the  house  of  a  sage-femme  who  had  living  with  her  her  mother,  suffering  from 
uterine  cancer ;  the  midwife  gave  her  mother  vaginal  injections  and  the  other 
attentions  her  state  required,  at  the  same  time  continuing  her  obstetric  work. 

Kaltenbach  has  stated  that  cases  are  known  in  which  midwives  suffering  with 
purulent  discharge  from  ulcerated  bone,  from  blennorrhoaa  of  dakryocystitis 
(Fritsch),  or  syphilitic  necrosis  of  the  jaw  (Dalton),  have  infected  a  number  of 
lying-in  women,  thus  causing  their  death. 

The  instances  are  many  in  which  hospital  surgeons  or  physicians  in  general 
practice,  going  from  patients  with  suppurating  wounds  to  women  in  confinement, 
have  carried  fatal  infection. 

Charpentier  mentions  the  following  case,  in  which  the  poison  was  communi- 
cated several  days  after  labor :  The  wife  of  a  physician,  the  seventeenth  day  after 
labor,  was  convalescing,  when  her  husband,  who  had  just  returned  from  visiting 
a  patient  with  diffuse  phlegmon  of  the  thigh,  had  the  unfortunate  thought  of 
examining  her  to  learn  whether  the  uterus  had  returned  to  its  normal  state. 
The  following  day  she  had  a  violent  chill,  followed  by  all  the  phenomena  char- 
acteristic of  a  purulent  affection,  and  died  the  thirty-third  day  after  labor. 

Local  disease  of  the  practitioner  has,  in  some  instances,  been  the  source  of  the 
poison.  Siredey  relates  the  history  of  a  physician  who,  in  consequence  of  a  sup- 
purating adenoma  of  his  neck,  had  introduced  a  rubber  tube  as  a  seton  ;  previous 
to  this  he  had  attended  eight  hundred  cases  of  labor  without  an  accident,  and 
now  three  women  whom  he  delivered  within  three  weeks  were  attacked  with 

1  Munchener  med.  Wochenschrift,  1893,  No.  46. 


654      THE  PATHOLOGY  OF  THE  PUERPERAL  STATE. 

puerperal  fever.  He  discontinued  obstetric  practice  until  the  suppuration 
ceased.  But  the  most  striking  illustration  was  given  by  a  Philadelphia  physician 
several  years  ago,  Dr.  David  Rutter.  He  had  nearly  seventy  cases  of  puerperal 
fever  occurring  within  less  than  twelve  months,  while  no  instance  of  the  disease 
was  observed  in  the  patients  of  any  other  accoucheur  practising  in  the  same  dis- 
trict. Harris1  states  that  Dr.  Rutter  had  ozaena,  which  in  time  much  disfigured 
him  from  its  effect  upon  the  contour  of  his  nose.  He  was  unfortunately  inocu- 
lated upon  his  index  finger  from  a  patient,  and  neglected  the  pustule.  He  had 
ninety-five  cases  of  puerperal  septicaemia  in  four  years  and  nine  months,  with 
eighteen  deaths.  Siredey,  in  referring  to  the  etiology  of  the  puerperal  fever 
which  so  frequently  occurred  in  this  physician's  practice  that  he  was  indeed  "  a 
walking  pestilence,"  says  that  the  explanation  suggested  by  Harris  was  true,  for 
Heiberg  has  discovered  septic  bacteria  in  the  muco-pus  of  an  analogous  case. 

In  lying-in  hospitals  the  contagion  may  be  communicated  by  using 
the  sponges,  basins,  syringes,  bed-clothing,  beds,  etc.,  that  have  been 
employed  in  infectious  cases.  Schroder  has  said  that  the  fluids,  even 
non-purulent  or  ichorous,  from  phlegmon  or  erysipelas,  diphtheria,  and 
scarlatina,  from  parts  of  dead  bodies,  especially  in  case  of  death  from 
septic  disease,  sanies  from  cancer,  and  putrefying  products  of  abortion, 
experience  has  taught  to  be  especially  feared. 

Kucher- states  that:  "Some  authors,  among  others  Atthill,  assert  that  the 
poisons  of  some  zymotic  diseases,  as  scarlatina,  typhus,  typhoid  fevers,  etc., 
become  so  changed  by  the  conditions  of  the  puerperal  state  as  to  produce  puer- 
peral fever.  This  assertion  has  often  been  made,  but  it  is  not  supported  by  any 
convincing  observations.  Neither  have  any  cases  of  scarlatina,  typhus,  or 
typhoid  fever  produced  by  puerperal  fever  been  observed." 

The  second  proposition  contained  in  the  definition  which  needs  expo- 
sition is  that  the  disease  is  heterogenetic.  Some  authorities  have  not 
been  satisfied  with  one  puerperal  fever,  but  insist  upon  several,  each 
having  a  different  etiology.  In  most  cases,  for  example,  nine  out  of 
ten,  careful  examination  soon  traces  the  disease  to  an  external  cause, 
so  that  all  will  admit  it  to  be  heterogeuetic.  But  again,  other  cases 
occur  for  which  no  external  cause  is  discovered,  and,  therefore,  the 
hypothesis  of  self-infection  or  autogenesis  is  proposed.  We  do  not 
thus  reason  as  to  other  contagious  diseases  when  we  are  unable,  as  we 
often  are,  to  discover  the  source  of  the  contagion.  For  example,  in 
many  cases  of  scarlet  fever  we  cannot  tell  whence  the  disease  came,  but 
we  never  say  it  was  generated  in  the  patient.  The  doctrine  of  auto- 
genesis is  a  confession  of  ignorance,  the  creed  of  fatalism,  the  cry  of 
despair.  It  is  more  rational  when  we  meet  with  cases  of  puerperal  in- 
fection whose  origin  we  do  not  know,  but  that  have  the  same  history 
as  others  the  source  of  which  we  can  trace  to  an  external  cause,  and 
that  have  the  same  evolution  and  the  same  infecting  power,  to  conclude 
that  they  too  come  from  like  sources,  though  the  connecting  thread  is 
so  fine  that  it  eludes  our  vision,  than  to  erect  an  altar  to  the  unknown 
god  of  autogenesis,  and  imagine  that  we  have  explained  the  mystery. 
Self-infection  means  that  the  house  sets  itself  on  fire,  and  that  the 
powder  magazine  is  exploded  without  any  mischievous  spark.  What 
security  can  the  practitioner  give  his  patient  when  the  foe  which  brings 
swift  death  is  created  within  her,  and  when  she  kills  herself?  This 

1  Note  to  Playfair's  Midwifery.  -  Puerperal  Convalescence. 


PUERPERAL  FEVER.  (555 

doctrine  of  the  autogenesis  of  puerperal  septicaemia  is,  to  my  mind,  the 
very  pessimism  of  obstetric  medicine.  Why  should  the  city  guard  its 
gates  when  the  enemy  can  already  be  in  the  citadel  and  begin  the  battle 
there?  Two1  of  the  best  recent  authorities  upon  puerperal  diseases 
have  very  positively  given  their  opinion  in  regard  to  the  question  of 
autogenesis  and  heterogenesis.  Siredey  said,  "  I  do  not  believe  in 
gravidic  auto-infection,  and  my  opinion  is  that  septic  puerperal  mala- 
dies are  due  to  hetero-infection."  Fritsch  is  still  more  positive:  "To 
admit  the  existence  of  a  spontaneous  infection  is  to  take  a  long  step 
backward." 

Wiuckel  regards  self-infection  as,  according  to  his  experience,  quite 
exceptional,  "  but,  like  the  belief  in  miasm,  it  relieves  the  conscience, 
and  therefore  will  always  retain  a  considerable  number  of  adherents." 

Dr.  Barnes,  who,  as  indeed  many  other  obstetric  authorities,  upholds 
the  doctrine  of  several  puerperal  fevers,  in  the  following  passage  ex- 
presses his  views  as  to  their  etiology.  Before  presenting  this  passage, 
it  may  be  said  his  position  in  regard  to  the  infection  of  the  puerpera  origi- 
nating from  erysipelas,  is  sustained  by  much  clinical  evidence  of  many 
years,  and  by  the  fact  that  there  is  a  strong  probability  the  strepto- 
coccus pyogenes  is  identical  with  the  streptococcus  of  erysipelas ;  but 
so  far  as  the  influence  of  the  other  diseases  mentioned,  the  reader  is 
referred  to  the  statement  of  Kucher  on  a  previous  page : 

"The  puerperal  fevers  may  be  classified  under  the  two  great  divisions  of  auto- 
genetic  and  heterogenetic.  a.  The  autogenetic  fevers  are :  1.  The  simple  excre- 
tory puerperal  fever,  the  result  of  endoaepsis,  or  the  arrest  of  the  excretion  of 
waste  stuff  of  involution:  it  is  especially  prone  to  arise  in  damp  cold  weather. 
This  form  complicates  all  other  fevers,  even  the  septicaemic  form.  2.  The  fever 
resulting  from  the  absorption  of  foul  stuff  from  the  parturient  canal,  either  from 
the  unbroken  mucous  surface,  or  by  the  open  mouths  of  vessels,  or  from  trau- 
matic surfaces ;  this  is  autoseptic.  This  form  is  also  likely  to  complicate  other 
fevers.  3.  This,  the  proper  septicaemic  puerperal  fever,  is  revealed  under  the 
forms  of  metritis,  peritonitis,  pelvic  cellulitis,  thrombosis  and  general  toxaemia. 
b.  The  heterogenetic  fevers  are  due  to  a  poison  from  without.  These  may  be 
divided  into  (1)  the  cadaveric  poison  which  wrought  such  havoc  before  the  days 
of  Semmelweis,  the  septic  stuff  from  other  puerperae,  animal  poisons  of  obscure 
origin;  and  (2)  the  known  zymotic  poisons,  as  smallpox,  scarlatina,  typhoid, 
diphtheria,  erysipelas." 

Here  are  at  least  five  different  forms  of  puerperal  fever !  How  are  they  to  be 
distinguished  from  each  other?  The  difficulty  is  increased  by  the  fact  that  Dr. 
Barnes  states,  "  number  1 "  complicates  all  other  fevers,  and  again,  that  "  number 
2"  is  likely  to  complicate  other  fevers.  How  indeed  at  the  bedside  know  whether 
the  disease  is  autogenetic,  or  heterogenetic  ?  Such  divisions  must  seem  to  most 
arbitrary,  and  show  analysis  pushed  to  an  extreme.  They,  in  my  opinion,  lead 
to  darkness  and  confusion  rather  than  to  light  and  order. 

In  general  it  may  be  stated  that  the  progress  of  knowledge  tends  to  diminish 
rather  than  to  increase  the  number  of  causes.  Hence  there  is  an  argument  of 
probability  against  the  views  that  have  been  presented.  It  will  be  admitted  that 
the  lessened  morbidity  and  mortality  of  puerperae  during  the  last  few  years  are 
due  to  the  fact  that  antiseptics  are  so  generally  used  in  obstetric  practice.  But 
how  could  these  have  any  effect  in  preventing  fever  caused  by  failure  of  excre- 
tion? If  there  be  ''foul  stuff"  to  be  absorbed  by  the  parturient  canal,  that  stuff 
has  become  foul  because  germs  of  decomposition  have  found  access  to  it. 


1  Auvard  bears  like  testimony:  "  Puerperal  septicaemia  is  undoubtedly  a  microbian  malady,  a 
"  f  and  essentially  opposite  to  eclampsia,  due  to  chemical  agent 
which  the  insufficient  elimination  causes  an  auto-intoxication." 


hetero-intoxication,  thus  absolutely  and  essentially  opposite  to  eclampsia," due  to  chemical  agents 
produced  by  the  organism  and  of  \  '  ' 


656  THE  PATHOLOGY  OF  THE  PUERPERAL  STATE. 

Kehrer,1  who  speaks  of  external,  internal,  and  mixed  infection — illustrating 
the  latter  by  supposing  that  the  obstetrician  introduces  an  aseptic  finger  into  the 
vagina  containing  infectious  matter,  and  carries  some  of  this  into  the  aseptic 
uterus,  finds  fault  with  my  statement,  asserting  that  while  it  is  just  and  reason- 
able to  criticise  carefully  all  cases  of  self-infection,  so  that  assistants  and  pupils 
may  not  be  careless,  but  be  ever  alert  and  watchful,  it  will  not  do  to  deny  the 
possibility  of  such  infection.  In  completing  the  picture  of  the  fortress  I  have 
given,  he  observes  that  "  hundreds  of  fortresses  have  fallen  because  the  enemy 
crept  in  or  traitors  were  in  the  camp.  A  faithful  commander  is  he  who  not  only 
keeps  a  watchful  eye  upon  the  besiegers,  but  also  upon  the  besieged.  Had  we 
no  enemies,  no  pathogenic  micro-organisms  in  the  genital  tract,  the  word  self- 
infection  might  be  dropped,  but  as  long  as  we  are  not  safe  from  this  internal 
enemy  it  must  be  retained." 

It  is  well  known  that  if  no  vaginal  examination  is  made  during  labor, 
the  occurrence  of  infection  is  exceedingly  rare.  Further,  the  more  pro- 
tracted and  difficult  the  labor,  the  more  frequently  interference,  manual 
or  instrumental,  is  required,  and  especially  if  artificial  removal  of  the 
placenta  is  necessary,  the  greater  the  liability  to  morbidity,  and  also 
mortality  in  the  puerperium.  These  facts  speak  for  the  introduction 
of  germs  from  without,  and,  therefore,  the  infection  is  heterogenetic. 
Nevertheless,  the  explanation  given  by  Kehrer  of  mixed  infection  may 
be  accepted  as  the  origin  of  puerperal  fever  in  rare  cases. 

Runge  states  that  the  pathogenic  germs  of  infection  are  almost  without  excep- 
tion streptococci,  according  to  Bumm.  Doderlein  has  concluded,  from  his  inves- 
tigations, that  the  normal  vaginal  secretion  never  contains  pathogenic  bacteria, 
and  this  has  been  upheld  by  other  investigators ;  the  acidity  of  the  vagina  pro- 
tects against  their  forming  colonies.  Bumm  holds  that  it  is  in  the  highest 
degree  improbable  that  pathogenic  cocci  may  have  a  virulence  in  the  progress 
of  normal  labor  so  as  to  be  injurious,  leading  to  self-infection.  Whether  in  a 
pathological  labor  such  virulence  may  be  developed  is  allowed  to  be  an  open 
question. 

PLACE  OF  ENTRANCE  OF  PUERPERAL  POISON.  Admitting  that 
different  forms  of  puerperal  fever  depend  upon  germs,  or  their  products, 
where  do  these  get  access  ?  Chiefly  through  wounds  of  the  cervix  in 
the  greater  number  of  cases,  carried  there  by  an  unclean  finger  in  many 
instances,  the  infection  almost  always  is  the  consequence  of  contact ; 
less  frequently  from  the  vagina  and  vulva,  and  still  less  from  the 
uterine  cavity.  This  is  the  general  statement  of  obstetric  writers  ;  but 
it  may  be  disputed. 

Bumm,2  referring  to  the  results  of  Widal,  in  examining  twelve  cases  of  fatal 
puerperal  septicaemia,  and  his  own  results,  asserts  the  endometrium  as  the  gate 
of  entrance  of  the  infection.  He  remarks:  "The  great  importance  which  the 
wound  of  the  puerperal  uterus  has  with  reference  to  the  generalization  of  the 
infection,  nevertheless,  does  not  exclude  the  possibility  of  infection  by  another 
way.  Moreover,  solutions  of  continuity  at  the  surface,  lesions,  wounds  situ- 
ated upon  any  part  of  the  genitals,  perineum,  vagina,  may  be  the  point  of  de- 
parture of  an  erysipelas,  of  a  general  infection.  But  usually  the  processes 
developed  at  the  level  of  the  perineum,  or  of  the  vagina,  remain  limited  to 
these  regions.  If  the  virus  does  not  reach  the  endometrium,  the  puerperal 
processes  cure  after  having  determined  a  more  or  less  acute  febrile  reaction." 

1  MUller's  Handbuch  der  GeburtshUlfe.  -  Arch.  f.  Gynakol.,  1891. 


PUERPERAL  FEVER.  657 

INFLUENCE  OF  THE  AIR.  It  has  been  asserted,  more  especially  by 
some  French  obstetricians/  that  the  uterus  may  be  infected  through  the 
blood  ;  infection  by  the  mephitism  of  the  air,  as  Gueniot  has  said,  may 
result  from  the  penetration  of  septic  vibrions  through  the  lungs.  Chaute- 
messe  asserts  that  puerperal  infection,  instead  of  coming  from  without, 
may  come  from  within,  germs  finding  their  way  from  the  blood  to  the 
uterus.  Prioleau  says  :  "  The  infected  blood  of  the  parturient  carries 
the  germs  to  the  place  of  the  placental  wound ;  pullulation  and  increase 
of  the  virulence  of  these  germs  in  the  favorable  conditions  (constant 
temperature  and  suitable  medium),  lessened  phagocytosis,  consequent 
upon  an  infection  already  existing." 

These  views,  however,  do  not  meet  with  general  professional  accept- 
ance ;  their  adoption  would  seem  a  long  step  backward  in  explaining 
the  etiology  of  puerperal  fever. 

TEMPERATURE.  Connected  with  the  condition  of  the  air  is  that  of 
temperature  in  causing  infection.  Hirsch2  shows  very  clearly,  as  gen- 
erally known  by  the  profession,  the  greater  prevalence  of  the  disease  in 
cold  than  in  warm  weather ;  but  he  also  states  that  the  influence  of 
cold  is  indirect,  that  it  is  reasonable  to  suppose  it  is  the  change  in  hy- 
gienic conditions  of  the  lying-in  hospitals  brought  about  by  the  cold 
season  which  furnishes  the  real  grounds  for  the  rise  of  the  sick-rate  and 
the  death-rate. 

MILDNESS  OR  SEVERITY  OF  INFECTION.  Bacteriology  has  by  no 
means  solved  all  the  problems  of  puerperal  disease ;  it  has  completely 
changed  many  beliefs  once  held,  but  it  has  also  presented  new  ques- 
tions ;  the  light  of  knowledge  has  increased,  but  it  has  also  revealed  a 
wider  area  of  ignorance.  Among  these  problems  is  this,  why  in  one 
case  the  infection  may  be  mild  and  in  another  very  dangerous.  Just 
as,  using  the  language  of  Kaltenbach,  an  etiological  classification  of 
puerperal  wound-diseases  is  impossible  according  to  the  botanical  quality 
of  the  active  germs,  so  from  the  same  agents  slight  as  well  as  grave  dis- 
eases arise,  and  besides  a  mixed  infection  may  occur. 

The  explanations  usually  offered  are  that  the  susceptibility  and  recep- 
tivity of  the  subjects  vary,  and  also  the  deleteriousness  of  the  germs 
themselves  is  not  constant,  and  the  number  of  these  may  be  greater  in 
the  severe  cases.  Not  only  a  protracted  labor  predisposes  to  infection — 
in  general  this  accident  is  more  frequent  after  the  birth  of  boys  than  of 
girls,  but  also  very  great  distention  of  the  uterus,  because  the  latter 
condition  is  not  uniformly  followed  by  perfect  contraction  ;  so,  too, 
among  important  influences  of  this  sort  must  be  placed  acute  anaemia, 
and  hence  in  part  a  relative  frequency  of  puerperal  fever  in  placenta 
preevia. 

That  the  greater  enlargement  of  uterine  vessels,  both  blood  and  lymph,  in 
completed  pregnancy,  and  especially  if  the  uterus  be  greatly  developed,  makes 
a  greater  liability  to  grave  disease,  than  if  the  pregnancy  have  an  early  inter- 
ruption, is  reasonable  and  probable.  Bumm,3in  his  histological  researches  upon 
puerperal  endometritis,  remarks  :  "  It  is  a  common  belief  that  a  general  septic 
infection  generalized,  is  a  rare  event  in  miscarriage,  though  endometritis  is  a 

1  Archives  de  Tocologie  et  de  Gynecologic,  January,  1894. 

a  Handbook  of  Geographical  and  Historical  Pathology.  3  Arch.  f.  Gyniikol.,  1891. 

42 


658  THE  PATHOLOGY  OF  THE  PUERPERAL  STATE. 

very  frequent  complication.  The  cause  of  this  fact  is  in  the  slight  development 
of  the  bloodvessels  and  lymphatics  in  the  first  months  of  pregnancy  (Chante- 
messe).  On  the  other  hand,  in  twin  pregnancy  and  in  deficient  retraction  of 
the  uterus  general  septic  infection  more  readily  occurs." 

TIME  OF  INFECTION.  This  may  be  in  pregnancy,  in  labor,  or  during 
the  lying-in.  Of  course,  that  a  pregnant  woman  may  be  infected 
an  artificial  traumatism,  as  in  a  rude  vaginal  examination,  or  in  an 
operation  upon  the  sexual  organs,  is  necessary ;  there  must  be  a  door 
opened  for  the  entrance  of  germs  or  of  their  products.  By  far  the 
most  frequent  infection  is  in  labor,  and  the  periods  of  special  danger 
are  the  first  and  the  last ;  that  is,  during  dilatation  of  the  os  and  the 
delivery  of  the  placenta,  especially  if  the  hand  is  introduced  into  the 
uterus. 

PUERPERAL  ULCER.  This  usually  appears  the  second  or  third  day 
after  labor,  occupying  some  portion  of  the  vulva.  It  is  grayish-yellow, 
with  irregular,  swelled  margins,  while  the  adjacent  parts  are  red ;  the 
labium  majus,  if  it  be  situated  upon  it,  is  cedematous.  The  ulcer  may 
be  the  starting-point  of  erysipelas,  but  this  is  rare,  and,  of  course,  is 
impossible  without  the  presence  of  the  erysipelas  coccus.  Its  covering 
has  sometimes  been  spoken  of  as  diphtheritic,  but  it  probably  would  be 
better  to  describe  it  as  diphtheroid. 

Spiegelberg  stated  that  the  membrane,  though  commonly  called  diphtheritic, 
has  nothing  whatever  to  do  with  true  diphtheria  (Birch-Hirschfeld) ;  it  consists 
of  fibrin  and  granular  detritus,  which  has  resulted  in  the  disintegration  of  the 
superficial  layer  of  the  injured  tissues  and  of  pus-corpuscles ;  it  is  an  accompa- 
niment of  the  regenerating  process  which  is  connected  with  the  suppuration. 
Siredey  and  Winckel  also  deny  that  the  membrane  is  diphtheritic. 

The  patient,  without  the  occurrence  of  a  chill,  and  with  little  dis- 
turbance of  the  pulse,  has  an  increased  temperature,  possibly  103°  F., 
and  chiefly  complains  of  a  feeling  of  fulness  and  burning  of  the  parts, 
and  urination  is  usually  painful. 

The  treatment  of  a  puerperal  ulcer  of  the  vulva  is  by  scrupulous 
cleanliness  and  antiseptics.  It  may  be  washed  with  .warm  water  and 
creolin  or  a  1  per  cent,  solution  of  lysol,  and  pencilled  with  tincture  of 
iodine  and  dusted  with  iodoform. 

PUERPERAL  COLPITIS.  Inflammation  of  the  vagina  may  result 
from  mechanical  injuries  in  labor,  or  it  may  be  caused  by  chemical  in- 
juries, as,  for  example,  when  the  vaginal  tampon  contains  one  of  the 
iron  salts,  or  strong  solutions  are  used  for  vaginal  injections;  especially 
is  evil  from  the  long-continued  use  of  the  tampon  to  be  feared,  simply 
from  its  pressure  causing  epithelial  detachment.  There  is  usually  fever, 
but  no  remarkable  participation  of  the  pulse.  The  treatment  will  be 
in  almost  all  cases  only  antiseptic  vaginal  injections  two  or  three  times 
in  twenty-four  hours ;  probably  lysol,  1  to  2  per  cent.,  may  be  most 
usefully  employed. 

Usually  external  injuries,  including  rupture  of  the  perineum,  even 
those  of  the  vagina,  are  rarely  the  causes  of  general  infection ;  local 
treatment  is,  as  a  rule,  sufficient  for  the  ulceratiou  which  may  result. 

PUERPERAL  ENDOMETRITIS.  This  is  one  of  the  most  frequent  forms 
of  disease  in  women  after  labor  or  miscarriage.  In  the  majority  of 


PUERPERAL  FEVER.  (359 

cases  it  remains  limited  to  the  inner  surface  of  the  uterus,  but  in  some 
it  is  the  forerunner  of,  or  associated  with,  the  gravest  manifestation  of 
puerperal  fever. 

In  regard  to  the  etiology  of  puerperal  eudometritis  the  following 
statement  of  Krouig,1  derived  from  his  recent  studies,  is  of  importance. 
Of  179  cases  of  endometritis  of  women  in  childbed,  75  were  caused 
by  the  streptococcus  pyogeues ;  4  by  the  staphylococcus  pyogenes 
aureus ;  50  by  the  gonococcus  of  Neisser ;  and  50  by  the  bacteria  of 
decomposition.  The  last,  therefore,  were  examples  of  saprsemia. 

The  studies2  made  at  Berlin  by  Goldscheider  contrast  somewhat  with  the  re- 
sults obtained  by  Kronig  at  Leipzig.  Thus  the  former  found  of  68  cases  of 
puerperal  fever  there  were  only  12  cases — 5  after  labor  at  term  and  7  after  abor- 
tion— of  saprsemia ;  moreover,  some,  at  least,  of  the  saprsernic  cases  followed 
rupture  of  the  perineum. 

The  characteristic  symptoms  of  puerperal  endometritis  are  fever, 
sensibility  of  the  uterus,  and  changed  lochial  flow.  Chill  or  chilliness 
marks  the  beginning  of  the  attack  and  is  followed  by  fever,  the  tem- 
perature reaching  102°— 101°  F.,  and  there  is  usually  a  morning  remis- 
sion ;  the  lochial  discharge  is  frequently  offensive  in  odor,  is  more 
abundant,  and  may  have  a  deep-brown  color. 

There  are  two  forms  of  puerperal  endometritis,  purulent  and  septic. 
In  the  former  chemical  products  of  putrefaction  are  absorbed  in  the 
uterine  cavity  and  cause  fever. 

Bumm  describes  the  superficial  layer  of  the  caduca  as  containing  numerous 
organisms — rods,  long  filaments,  and  cocci — forming  colonies ;  but  a  layer  of 
granular  matter  is  found  at  the  level  of  the  muscular  substance,  forming  what 
he  calls  the  zone  of  reaction,  and  micro-organisms  do  not  penetrate  this  zone. 

In  septic  endometritis,  beside  the  germs  of  putrefaction,  more  or  less  numer- 
ous, according  to  the  case,  there  are  the  characteristic  cocci  in  chain-form.  But 
here  again  the  granular  zone  is  a  barrier  to  the  penetration  of  the  germs  into  the 
parenchymatous  structure. 

Those  cases  in  which  a  general  infection  begins  from  septic  endometritis  will 
be  considered  hereafter  with  reference  to  the  entrance  of  germs. 

TREATMENT.  An  ice-bag  is  placed  over  the  uterus  to  excite  its 
contraction,  and  this  action  is  assisted  by  ergot.  If  the  offensive 
odor  of  the  lochia  does  not  disappear  by  the  use  of  vaginal  injections, 
those  in  the  uterus  are  generally  regarded  as  indicated.  For  this  pur- 
pose an  irrigator  or  fountain  syringe  will  be  employed,  with  Bozeman's 
catheter  as  modified  by  Fritsch.  A  solution  of  corrosive  sublimate  or 
a  strong  solution  of  carbolic  acid  will  not  be  used,  but  rather,  lysol  or 
creolin.  Care  must  be  taken  that  no  air  enters  during  the  irrigation, 
that  there  is  a  free  exit  for  the  fluid  from  the  uterus,  and  that  the  irri- 
gator is  held  but  slightly  above  the  level  of  the  patient,  so  that  the 
entering  stream  has  but  little  force.  Even  with  all  these  precautions 
unpleasant  symptoms  may  follow  irrigation.  For  example,  the  patient 
has  a  chill  and  a  higher  temperature  for  a  time  than  she  had  before. 

1  Op.  cit. 

2  Klinische  und  bakteriologiscUe  Mittheilungen  Uber  Sepsis  puerperalis.    CharitS-annalen  xviii, 
Cent.  f.  Gynakol.,  1894. 


660 


THE  PATHOLOGY  OF  THE  PUERPERAL  STATE. 


Kaltenbach,  while  in  doubt  as  to  the  cause,  whether  from  infection 
through  fresh  traumatism  caused  by  the  tube,  destruction  of  red  cor- 
puscles, the  entrance  of  septic  stuff,  or  of  the  injected  fluid  into  blood- 
vessels, etc.,  regarded  the  symptoms  as  of  no  unfavorable  character. 

In  rare  instances  the  patient  is,  during  an  irrigation,  attacked  with 
sudden  dyspnoea,  and  even  convulsions  with  unconsciousness  may  fol- 
low. Therefore,  let  the  obstetrician  watch  the  patient's  countenance 
during  the  operation,  and  cease  at  the  first  manifestation  of  distress. 

Uterine1  injections  are  not  now  regarded  with  as  much  favor  as  they 
were  a  short  time  since  in  the  treatment  of  endometritis.  Thus, 
Schrader2  condemns  them,  and  Kronig3  observes  :  "  Clinical  experience, 
however,  has  taught  us  that  washing  out  the  uterus  brings  no  benefit. 
Also  experimental  examinations  made  by  the  reporter  prove  that  the 
various  antiseptics  do  not  destroy  the  germs.  Instead  of  the  local,  the 
general  therapeia  is  of  the  greatest  importance."  Nevertheless,  while 
uterine  irrigation  should  not  be  rashly  resorted  to,  and  when  used  it 
should  be  with  the  precautions  mentioned,  there  will  in  many  cases  fol- 
low the  discharge  of  retained  clots,  fragments  of  membranes,  or  of 
placenta  effected  by  the  washing,  lessened  temperature,  and  rapid  re- 
covery. 

PARAMETRITIS,  PERIMETRITIS.  Inflammation  of  the  connective 
tissue  adjacent  to  the  uterus  is  called  parametritis,  sometimes  circum- 
scribed parametritis,  while  perimetritis  is  applied  to  inflammation  of 
the  peritoneum  belonging  to  the  uterus  or  adjacent  to  it.  In  some  cases 
the  two  forms  of  disease  are  associated. 


FIG.  268. 


FIG.  269. 


SCHEME  OF  EXUDATES  IN  PARAMETRITIS. 
(After  FEHLING.) 


SCHEME  OF  EXUDATES  IN  PERIMETRITIS. 
(After  FEHLING.) 


Parametritis  generally  originates  from  a  tear  of  the  cervix  or  a  deep 
tear  of  the  perineum  ;  in  other  cases  it  is  caused  by  a  pressure-necrosis 
of  the  cervix  or  of  the  vaginal  vault  (Kaltenbach).  If  from  pressure- 
necrosis,  saprophytes  are  found  in  the  exudation ;  gonococci,  too,  have 
been  considered  as  possible  causes  of  the  inflammation  ;  but  the  usual 

1  The  prefix  intra,  as  commonly  used,  is  unnecessary ;  it  would  be  just  as  appropriate  to  speak 
of  intra-vaginal  injection  or  irrigation. 

4  Woher  der  therapeutische  Misserfolg  der  Antisepsis  beim  Puerperalfieber?    Leipzig,  1894. 
3  Op.  cit. 


PUERPERAL  FEVER.  661 

germs  found  in  the  effusion  are  staphylococci  and  streptococci.  The 
exudate  may  be  on  one  or  on  both  sides. 

Two  forms  of  parametritis  are  recognized,  mild  and  grave,  the  latter 
occurring  in  severe  sepsis ;  fortunately,  the  former  is  much  the  more 
frequent.  The  disease  may  begin  immediately  after  labor,  a  chill  oc- 
curring and  the  temperature  rising  to  103°-104°  F. ;  but  in  most  cases 
the  disease  is  much  later,  often,  too,  insidious  in  its  advent ;  it  may  occur 
even  five  to  ten  days  after  delivery.  In  rare  instances  there  may  be 
no  change  in  the  pulse  or  temperature.  Ahlfeld  mentions  having  seen 
four  such  cases.  If  fever  occurs,  it  may  have  morning  remissions,  and 
lessens  in  a  short  time. 

The  characteristic  effusion  occurs  at  the  side  of  the  cervix  and  in  the 
base  of  the  broad  ligament.  At  first  this  exudate  cannot  be  recognized 
by  vaginal  touch,  only  a  resistance  and  increased  sensibility  ;  but  after 
a  few  days  a  tumor  the  size  of  a  hen's  egg,  possibly,  or  even  as  large 
as  the  fist,  sometimes  larger,  may  be  found  in  many  cases. 

The  tumor,  if  the  exudate  is  only  upon  one  side,  pushes  the  uterus  to 
the  opposite  side.  In  the  great  majority  of  cases,  whether  a  distinct 
tumor  is  formed  or  not,  absorption  of  the  effusion  occurs,  and  recovery 
is  not  greatly  delayed.  In  some  cases  suppuration  takes  place,  and  the 
abscess  may  spontaneously  open  into  the  rectum,  the  .vagina,  or  the 
bladder,  more  rarely  into  the  uterus,  or  above  Poupart's  ligament,  and 
still  more  rarely  into  the  peritoneal  cavity. 

Depending  upon  the  position  and  size  of  the  exudate  the  patient  may 
have  numbness,  pain,  and  paresis  of  the  limb  belonging  to  the  side 
affected ;  again,  an  effusion  in  the  vicinity  of  the  psoas  muscle  may 
compel  her  to  keep  the  knee  bent  and  the  hip  immobile. 

The  diffuse  swelling  in  the  vicinity  of  the  uterus  and  its  doughy 
feeling  are  regarded  as  characteristic;  bimanual  examination  will  be 
useful  after  eight  to  ten  days  if  the  exudate  is  large.  Runge  states 
that  in  perimetritis,  a  local  peritonitis,  the  pain  and  the  fever  are  quite 
prominent,  while  circumscribed  parametritis  is  more  insidious  in  its  at- 
tack, and  there  is  early  formation  of  an  exudate.  But  it  should  be 
remembered  that  the  two  affections  may  be  associated,  and  that  even  in 
autopsies  it  is  sometimes  impossible  to  decide  which  was  the  primary 
disease. 

The  prognosis  is  generally  favorable.  In  rare  cases  the  patient  may 
die  from  exhaustion  in  consequence  of  prolonged  suppuration ;  and  in 
others  in  which  the  exudate  fs  considerable  months  may  pass  before 
complete  recovery ;  in  still  other  cases  the  nutrition  of  the  uterus  and 
ovaries  by  the  abundant  proliferation  of  connective  tissue  is  so  interfered 
with  that  sterility,  amenorrhoea,  and  a  premature  menopause  follow.1 

In  the  treatment  antiseptic  vaginal  injections  will  be  employed  if  the 
lochia  are  at  all  offensive  in  odor,  ice  will  be  applied  to  the  abdomen 
over  the  inflamed  part ;  this  application,  it  is  believed,  prevents  the 
further  wandering  of  micrococci  by  causing  contraction  of  lymphatics 
and  bloodvessels,  and  certainly  it  contributes  much  to  the  patient's  com- 
fort ;  pain  is  relieved  and  peristalsis  prevented  by  opium — Ahlfeld 
asserts  that  ice  and  opium  are  sovereign  means  in  beginning  parame- 

i  Ahlfeld. 


662  THE  PATHOLOGY  OF  THE  PUERPERAL  STATE. 

tritis;  calomel  and  castor-oil  may  be  used  in  case  constipation  is  not 
removed  by  suitable  diet  or  by  rectal  injections. 

If  this  treatment  has  failed,  and  the  exudate  does  not  notably  lessen 
by  the  third  week,  the  internal  administration  of  potassic  iodide  and  the 
application  to  the  abdomen  over  the  tumor  of  Churchill's  tincture  of 
iodine  are  generally  recommended ;  there  may  be  used  also  the  wet 
pack,  more  especially  at  night. 

If  suppuration  should  occur,  a  free  opening  and  drainage  are  indi- 
cated. Fritsch1  has  recommended  early  opening  of  the  abscess,  from 
the  second  to  the  beginning  of  the  third  week,  stating  that  cure  is  thus 
promptly  effected.  The  following  is  his  method  of  operating :  He 
makes  an  incision  in  the  vagina  at  the  most  prominent  part  of  the  para- 
metritic  tumor;  spurting  vessels  are  immediately  ligated ;  the  finger  is 
used  again  to  feel  the  tumor  through  this  opening,  and  very  carefully 
the  knife  opens  the  pus-collection.  The  pus  escaping,  the  opening  is 
enlarged  with  the  finger  or  with  the  forceps,  and  the  sac  is  washed  out 
with  a  stream  of  water  having  slight  force,  a  double  catheter  being 
used.  Then  the  finger  is  cautiously  passed  into  the  cavity  to  explore 
it,  and  finding  narrow  recesses  in  it,  they  are  widened  so  that  all  the 
contents  can  readily  escape.  I^ext  the  sac  is  packed  gently  with  iodo- 
form  gauze.  The  after-treatment  is  daily  washing  out  the  sac  and  in- 
troducing a  fresh  tampon. 

PERIMETKITIS,  having  as  its  synonymes  circumscribed  peritonitis 
and  pelviperitonitis,  begins  with  a  chill,  followed  by  fever,  the  tem- 
perature rising  to  104°  F.  or  somewhat  higher.  The  pain  is  more  in- 
tense than  in  parametritis ;  it  is  sharp,  knife-like,  characteristic  of 
inflammation  of  serous  membranes.  There  may  be  vomiting,  there  is 
great  tenderness  in  the  lower  part  of  the  abdomen,  and  this  is  tym- 
panitic.  The  causes  of  the  disease  are  extension  of  a  parametritis 
or  of  an  ovaritis  to  the  peritoneum,  pressure-necrosis  of  the  posterior 
wall  of  the  cervix  and  of  the  vaginal  vault,  and,  according  to  Kalten- 
bach,  there  may  be  peritonitis  in  completely  intact  sexual  organs.  It 
is  also  commonly  taught  that  a  peritoneal  inflammation  may  result  from 
an  extension  of  an  endometritis  to  the  tubes,  and  their  purulent  con- 
tents escaping  into  the  abdominal  cavity.  The  researches  of  Burnm 
render  this  etiology  doubtful,  so  far  as  such  extension  of  disease  of  the 
endometrium  is  concerned.  He  states2  that  he  believes  general  peri- 
tonitis from  streptococci  results  from  the  direct  penetration  through 
the  uterine  wall  to  the  serous  membrane  of  the  infectious  germs,  and 
propagation  by  the  oviduct  is  absolutely  exceptional.  But  this  is  far 
from  denying  that  a  pyosalpinx  antedating  pregnancy  may  rupture  during 
labor  or  lying-in,  and  the  escaping  pus  cause  peritonitis. 

Peritoneal  inflammation  is  usually  soon  followed  by  an  exudate 
which  becomes  encapsulated,  shut  off  from  the  general  peritoneal  cavity. 
In  the  majority  of  cases  recovery  takes  place  without  injury  to  parts, 
but  in  others  adhesions  between  coils  of  intestines  and  then  with  the 
broad  ligaments,  the  abdominal  wall,  tubes,  ovaries,  and  uterus  may 
ensue,  and  in  still  others  suppuration,  the  pus  usually  finding  an  exit 
through  the  rectum,  or  the  vagina,  or  bladder. 

1  Krankheiten  der  Frauenh.    6th  edition,  1894.  2  Op.  cit. 


PUERPERAL  FEVER.  663 

In  the  treatment  absolute  rest  for  the  patient  is  first  in  importance. 
Many  would  begin  with  Epsom  salt,  and  then  use  the  ice-bag  and 
opium.  Vaginal  injections  of  an  antiseptic  solution  are  indicated  if  the 
discharge  is  offensive,  and  washing  out  the  uterus  with  a  similar  solu- 
tion if  purulent  endometritis  is  present.  Later,  after  the  fever  has 
gone,  a  blister  may  hasten  absorption,  and  iodine  may  be  used  to  the 
vaginal  vault,  and  also  tampons  of  icthyol  and  glycerin  may  be  em- 
ployed for  the  same  purpose.  Suppuration  having  occurred,  the  pus 
must  be  given  early  exit. 

Range  asserts  that  the  majority  of  so-called  pelvic  abscesses  are  at  all  events  of 
parametritic  origin — a  statement  that  at  least  the  majority  of  American  practi- 
tioners will  be  slow  to  accept. 

Ahlfeld  suggests  that  probably,  more  frequently  than  has  hitherto  been  recog- 
nized, the  bacterium  coli  commune,  whose  entrance  through  the  intestinal  wall 
is  favored  by  the  disorders  of  nutrition,  is  present  in  these  encapsulated  centres, 
and,  therefore,  the  adhesions  of  the  serous  covering  of  the  intestine  with  other 
serous  parts. 

PHLEGMASIA  ALBA  DOLENS.  This  form  of  disease  usually  occurs 
from  the  fourth  to  the  twelfth  day  after  delivery,  but  there  may  be  an 
interval  of  two  or  three,  or  even  five  or  six  weeks.1  "  Considered  suc- 
cessively as  a  milk-metastasis,  a  rheumatic  affection,  a  neuritis,  an 
inflammation,"  various  theories  have  been  advanced  to  explain  this 
affection  of  women  in  childbed.  The  chief  characteristics  are  pain  and 
swelling  of  one  of  the  lower  limbs,  this  swelling  being  of  a  white  color. 
One  of  the  oldest  theories  in  regard  to  the  disease  is  that  which  attrib- 
uted it  to  a  deposit  of  milk  in  the  affected  member,  and  which  is  per- 
petuated in  the  once  professional  but  now  only  popular  designation  of 
milk-leg.  The  theory  of  inflammation  of  the  connective  tissue,  and 
then  that  which  made  it  depend  upon  inflammation  of  the  veins,  prob- 
ably were  next  in  order.  The  last  was  advocated  by  Davis  in  1817, 
and  is  now  generally  accepted.2  Inflammation  of  the  lymphatics  has 
been  maintained  by  some  as  the  cause.  By  still  others  it  is  claimed  that 
spontaneous  coagulation  of  the  blood  occurs  in  the  affected  vessels  ;  the 
hyperinotic  condition  of  the  blood  is  an  admitted  fact,  and  then  there  is 
assumed  an  inopexia,  which  is  the  final  agent  in  producing  a  physio- 
logical thrombosis,  and  the  lesions  of  the  walls  of  the  vessel  are  consecu- 
tive to  its  spontaneous  obstruction.  As  has  been  already  stated,  it  is 
now  generally  held  that  phlegmasia  alba  dolens  of  childbed  is  caused 
by  phlebitis — that  phlebitis  being  an  extension  of  the  disease  from  the 
vessels  of  the  uterus. 

Symptoms.  Pain  and  swelling  are  the  most  striking  characteristics 
of  the  affection.  Pain  precedes  the  swelling,  and  in  many  cases  is  felt 
for  some  hours  in  the  lower  part  of  the  abdomen  at  the  pelvic  inlet ; 
possibly  a  chill  occurs  before  the  pain.  With  or  without  the  pelvic 
pain  first  occurring,  pain  is  felt  below  Poupart's  ligament,  and  soon 
extends  down  the  thigh  to  the  leg.  The  swelling  follows,  and  may 

1  Greslon  has  given  (Nouv.  Arch.  d'Obstetrique  et  de  Gynecologic)  a  case  of  phlegmasia  alba 
dolens  coming  on  the  twenty-seventh  day  after  delivery. 

I  had  a  case  primarily  of  infectious  phlebitis  in  which  this  adhesive  phlebitis  did  not  appear 
until  four  weeks  after  labor  ;  the  patient  recovered  after  a  very  long  illness. 

"  Kaltenbach  has  held  that  the  disease  may  arise  without  thrombosis  of  the  femoral  vein,  in 
consequence  of  lymph-stasis. 


664      THE  PATHOLOGY  OF  THE  PUERPERAL  STATE. 

begin  in  the  gluteal  region,  or  upon  the  upper  anterior  face  of  the  thigh, 
thence  extending  to  the  leg  and  foot ;  the  rapidity  of  the  extension  is 
so  great  that  in  some  cases  the  entire  limb  is  involved  within  a  few 
hours.  The  swelling  is  so  uniform  that  the  limb  has  a  symmetrical 
shape,  or  resembles  a  truncated  cone,  the  base  of  which  is  at  the  upper 
end  of  the  thigh ;  it  is  so  great  that  sometimes  the  limb  seems  double 
its  natural  size.  In  most  cases  it  is  limited  to  the  member,  but  in 
some  it  involves  the  hypogastric  region.  The  skin  is  white,  tense,  and 
shining.  By  palpation,  which  ought  to  be  done  very  gently,  the  ob- 
structed veins  are  felt  as  solid,  irregular  cords.  The  limb  is  sensitive 
to  pressure  where  the  inflamed  vessels  are  felt,  but  after  the  first  day 
or  two  no  severe  spontaneous  pain,  but  chiefly  discomfort,  is  experi- 
enced ;  the  member  becomes  inert,  useless,  the  patient  being  unable  to 
move  it. 

In  almost  all  cases  premonitory  symptoms  occur ;  in  some  the  disease 
may  appear  in  the  course  of  a  more  or  less  severe  attack  of  pyaemia, 
while  in  others  there  have  been  occasional  manifestations  of  fever  and 
abdominal  pain,  a  sort  of  masked  infection,  and  a  threatening  of  more 
serious  danger,  or,  at  least,  some  deviation  from  normal  convalescence. 
The  occurrence  of  the  disease  without  some  prior  evidence  of  a  patho- 
logical condition  of  the  uterus,  or  in  its  vicinity,  is  quite  exceptional. 

PEOGRESS  AND  TERMINATION.  Fever  with  some  pain  continues  for 
about  two  weeks,  and  then  in  the  great  majority  of  cases  the  swelling 
begins  to  subside,  the  subsidence  taking  place  very  much  more  slowly 
than  the  accession.  In  rare  instances  the  other  limb  is  also  affected.  Reso- 
lution is  the  usual  termination,  but  the  limb  is  a  long  time  recovering 
its  lost  power  and  natural  feeling,  being,  as  has  been  said,  like  a  wooden 
leg ;  even  for  months  the  foot  and  leg  swell  after  exercise  or  standing. 
In  some  instances  a  permanent  oedema  is  the  result.  Among  the  perils 
of  the  patient  are  breaking  down  of  the  clot,  with  consequent  general 
infection,  or  detachment  of  a  portion  of  it,  with  pulmonary  embolism, 
and  sudden  or  rapid  death  follows. 

CRURAL  PHLEGMON.1  This  is  a  rarer  affection  in  the  puerpera  than  the 
preceding.  It  is  a  phlegmon  of  the  thigh,  with  primary  disease  of  the  skin  or 
the  subcutaneous  or  intermuscular  cellular  tissue ;  for  instance,  in  the  course 
of  parametritis,  in  which  the  vessel  walls  may  take  part,  when  at  times  even 
secondary  thrombi  form  in  them,  but  in  which  they  are  not  always  implicated. 
The  treatment  advised  by  Winckel  is  early,  free,  long,  and  deep  incisions 
through  the  diseased  integument  in  order  to  relieve  the  swelling,  and  evacuate, 
as  soon  as  possible,  the  pus  which  has  been  formed.  The  wounds  are  then 
irrigated  with  a  solution  of  carbolic  acid,  drained,  and  treated  with  iodoform 
powder. 

THE  TREATMENT  OF  PHLEGMASIA  ALBA  DOLENS.  Active  treat- 
ment of  this  manifestation  of  puerperal  infection  should  not  be  em- 
ployed, and  hence  leeching,  cupping,  and  blistering,  which  were  once 
used,  are  to  be  rejected.  In  regard  to  the  last,  Siredey  says  he  posi- 
tively proscribes  blisters  because  of  the  injurious  action  which  they 
have  upon  the  kidneys,  and  of  the  predisposition  to  gangrene  of  a 
member  the  circulation  of  which  is  profoundly  disturbed.  As  the 

i  Winckel. 


PUERPERAL  FEVER.  665 

greatest  peril  to  life  iu  the  affection  arises  from  the  detachment  of  a 
portion  of  the  clot  and  consequent  pulmonary  embolism,  the  limb 
should  be  kept  at  perfect  rest,  and  all  friction  of  it  avoided.  Barker 
advised  elevating  the  limb  at  an  angle  above  the  trunk  by  raising  the 
lower  part  of  the  mattress,  "not  so  much  to  favor  the  gravitation  of 
fluids  back  toward  the  trunk,  as  to  retard  the  gravitation  of  the  blood 
toward  the  limb."  Siredey,  however,  objected  to  the  elevation  of  the 
member  on  the  ground  that  it  facilitates  the  detachment  of  clots,  and  he 
directs  it  to  be  kept  in  a  horizontal  position.  Certainly  the  elevation 
does  not  add  to  the  comfort  of  the  patient,  and  it  is  better  to  follow 
Siredey's  direction.  The  affected  member  should  be  protected  from  the 
pressure  of  the  bed-clothes,  and  wrapped  in  cotton  batting,  then  covered 
with  oil-silk.  Where  there  is  great  pain  in  the  limb  Barker  advised  a 
liniment  composed  of  six  ounces  of  the  compound  soap  liniment,  one 
ounce  and  a  half  of  laudanum,  and  half  an  ounce  each  of  tincture  of 
aconite  root  and  extract  of  belladonna.  Opium  will  be  necessary  in 
many  cases  to  relieve  pain  and  restlessness  and  to  secure  sleep. 

After  all  fever  has  ceased,  and  the  pain  and  oedema  have  disappeared, 
the  patient  may  be  changed  from  the  bed  to  a  lounge,  then  in  a  few  days 
sit  for  a  while  in  a  chair,  and  after  this  she  may  stand  or  walk ;  an  im- 
mediate change  from  the  horizontal  to  an  erect  position  must  be  posi- 
tively forbidden.  When  she  begins  to  use  the  limb  a  properly  applied 
bandage  adds  very  greatly  to  her  comfort,  and  to  some  extent  prevents 
the  swelling  which  may  for  some  months  occur  after  exercise. 

SAPR^EMIA.  This  name,  originating  with  Matthews  Duncan,  1880, 
is  applied  to  a  blood-poisoning  from  the  absorption  of  chemical  products 
resulting  from  the  action  of  saprophytes ;  germs  themselves  do  not  enter 
the  blood  or  the  lymph.  It  is  sometimes  called  a  putrid  fever,  or  a  re- 
sorption  fever.  The  product  of  the  action  of  the  bacteria  of  decompo- 
sition may  be  found  in  some  part  of  the  genital  canal,  e.  g.,  in  certain 
cases  of  rupture  of  the  perineum,  or  in  the  uterine  cavity,  as  in  purulent 
endometritis. 

In  the  majority  of  cases  the  discharge  is  offensive,  whether  from  the 
uterine  cavity  or  not,  and  sapraemia  may  begin  as  in  a  grave  form  of 
puerperal  fever,  but  usually  the  temperature  is  not  more  than  101.5°. 
Local  treatment  promptly  ends  the  disease  ;  of  course,  this  local  treat- 
ment is  applying  antiseptics. 

THE  SEVERE  FORMS  OF  PUERPERAL  INFECTION.  Having  con- 
sidered the  milder  manifestations  of  puerperal  wound-diseases,  we  have 
finally  to  present  those  of  a  grave  character.  They  are  divided  accord- 
ing as  the  infectious  agent  enters  the  lymphatics  or  the  veins,  the  first 
being  included  under  Septiecemia,  and  the  second  under  Pyaemia. 

Autopsies  do  not  always  show  a  perfect  boundary-line  between  septi- 
caemia and  pyaemia,  and  therefore  a  mixed  infection  must  be  admitted, 
as,  indeed,  clinical  observation  proves.  So,  too,  saprsemia  and  septi- 
caemia may  be  associated,  and  here  again  a  mixed  infection  is  to  be 
acknowledged. 

The  former  variety  of  mixed  infection  does  not  rest  entirely  upon  clinical 
observation  and  autopsies,  but  has  also  been  proved  etiologically  by  Bumm,  for 
he  found  in  the  lymphatics  and  veins  of  the  uterus,  in  one  case,  streptococci. 


666  THE  PATHOLOGY  OF  THE  PUERPERAL  S1ATE. 

ENTRANCE  OP  GERMS  IN  LYMPH-VESSELS  AND  IN  BLOODVESSELS. 
Bumm  states  that,  examining  a  great  number  of  sections  of  the  uterus  of  a 
woman  dead  from  septicaemia,  he  has  always  succeeded  in  discovering  the 
passage  of  germs  from  the  surface  into  the  openings  of  the  lymph-vessels ; 
at  some  points  these  fine  entrances  are  completely  filled  with  germs, 
and  the  cocci  may  be  found  penetrating  the  neighboring  tissues.  If  the 
process  is  more  advanced,  the  lymphatics  are  filled  with  cocci,  and  from 
this  centre  the  germs  radiate  in  thick  trains  toward  the  muscular  sub- 
stance. In  the  vicinity  a  zone  of  reaction,  formed  of  round  cells,  is 
seen.  If  death  is  delayed,  this  circumscribing  inflammation  may  cause 
liquefaction  of  all  the  infected  mass,  promoted  by  diapadesis  of  white 
cells,  transforming  it  into  a  purulent  cavity.  The  condition  which  has 
been  described  as  lymph-spaces  filled  with  pus  in  the  wall  of  the  septic 
uterus  are  really  purulent  cavities,  the  consequence  of  destruction  of  the 
surrounding  muscular  tissue.  He  has  several  times  found  the  muscular 
tissue  and  the  lymphatics  up  to  the  serous  membrane  abounding  in  cocci. 
The  tubes  in  their  internal  half  had  a  sound  mucous  membrane,  and  no 
cocci  were  found,  but  cocci  were  in  the  pavilion  and  extending  as  far  as 
the  contracted  portion  of  the  tube.  In  all  cases  he  found  that  infection 
of  the  tube  was  propagated  from  the  abdominal  cavity. 

In  the  uterus  of  a  patient  dead  from  pyaBmia  he  found  in  the  part  of 
a  thrombus  at  the  placental  site,  adjacent  to  the  surface  of  the  caduca, 
both  streptococci  and  saprophytes  ;  granular  degeneration  of  the  throm- 
bus was  seen  ;  more  deeply  in  the  muscular  substance  only  streptococci 
were  found,  the  saprophytes  left  behind.  The  streptococcus  invasion 
proceeds  in  the  course  of  the  axis  of  the  thrombus,  and  with  the  advance 
of  the  germs  granular  degeneration  of  the  thrombus  equally  takes  place. 
As  the  infection  advances  the  walls  of  the  veins  may  show  germs  and 
their  pullulation.  The  veins  of  the  broad  ligaments  are  also  the  seat  of 
infected  thromboses. 

CLINICAL  COURSE  OF  LYMPHANGITIS,  OR  SEPTICAEMIA.  It  seems 
probable,  from  the  preceding  researches,  that  the  infection  enters  through 
the  wound  at  the  placental  site,  in  the  majority  of  cases  following  septic 
endometritis,  but  infection  is  also  believed  to  occur,  as  previously  stated, 
from  tears  of  the  cervix  and  of  the  vaginal  entrance.1 

The  disease  usually,  not  always,  begins  with  a  chill,  and  this  begin- 
ning is  seldom  delayed  beyond  three  days.  High  fever  and  increased 
frequency  of  the  pulse  are  observed ;  the  temperature  may  be  from 
103°  to  105°,  and  the  pulse  120  to  130.  Morning  remissions  are 
observed ;  the  temperature  may  then  be  only  a  degree  or  two  above  the 
normal.  The  patient  is  sleepless,  restless,  without  desire  for  food, 
probably  has  nausea  and  vomiting,  and  complains  of  headache.  The 
abdomen  becomes  tympanitic,  possibly  from  intestinal  paralysis  result- 
ing from  absorption  of  ptomaines.  The  lochial  discharge  is  often  quite 
offensive,  but  the  absence  of  such  odor  ought  not  to  delude  the  prac- 
titioner into  the  false  hope  that  peril  is  absent,  or  only  slight,  for  a 
woman  may  quickly  perish  without  such  sign  being  present.  In  con- 

i  "Diffuse  septic  peritonitis,  the  malignant  form  of  puerperal  peritonitis,  is  developed  chiefly 
from  a  severe  septic  endometritis ;  much  more  rarely  is  the  entrance  in  the  cervix  or  in  the 
vagina."  (Ahlfeld.) 


PUERPERAL  FEVER.  667 

sequence  of  the  abdominal  disteution  the  respiration  is  shallow  and  the 
blood  may  fail  to  receive  sufficient  oxygen,  and  hence  the  face  is  slightly 
cyanosed.  In  rare  cases  pleuritis  and  pericarditis  occur,  this  fresh 
invasion  being  generally  marked  by  a  chill. 

The  urine  is  usually  scanty,  and  frequently  is  albuminous.  The 
secretion  of  milk  is  lessened  and  disappears. 

While,  as  a  rule,  the  bowels  are  confined,  exceptionally  diarrhoea 
occurs,  but  without  lessening  the  meteorism. 

As  a  rule,  distinct  peritoneal  symptoms  are  present,  varying  from 
slight  to  severe.  In  some  cases  the  tenderness  to  the  touch  is  great, 
while  in  others  it  is  found  only  upon  firm  pressure  on  one  or  both  sides 
of  the  womb,  or  upon  this  organ  and  in  the  umbilical  region.  In  many 
cases  peritoneal  pain  rhay  fail,  or  be  so  slight  that  the  danger  of  the 
disease  is  not  recognized.  The  entire  cessation  of  pain,  with  increasing 
exhaustion,  is  frequently  a  forerunner  of  swift  death.  The  condition  of 
the  mind  varies.  Even  at  first  there  may  be  some  mental  dulness, 
though  this  is  not  characteristic ;  the  intellect,  on  the  other  hand,  may 
be  perfectly  clear  until  just  before  the  end,  and  then  one  patient  may  be 
hopeful  of  recovery,  and  speak  of  the  future  of  her  life,  while  another 
realizes  her  peril,  begging  the  doctor — how  pitiful  the  prayer — to  save 
her. 

A  fatal  end  may  occur  within  the  first  three  days,  but  more  fre- 
quently this  happens  in  the  second  week. 

PROGNOSIS.  The  sooner  the  disease  follows  labor  the  more  probable 
a  fatal  result.  Excessive  vomiting,  a  notable  quantity  of  albumin  in 
the  urine,  and  especially  the  condition  of  the  pulse  as  to  frequency  and 
force,  darken  the  prognosis ;  so,  too,  the  complications  that  may  occur 
which  have  been  mentioned  are  unfavorable. 

TREATMENT.  In  case  endometritis  has  preceded  the  attack,  local 
treatment  is  indicated  when  the  lochial  discharge  has  an  offensive  odor ; 
this  will  be  first  limited  to  antiseptic  vaginal  injections — only  in  rare 
cases  will  benefit  result  from  washing  out  or  curetting  the  womb,  and 
then  most  probably  solely  at  the  beginning  of  the  peritoneal  invasion. 
Pain  in  the  uterus  or  adjacent  parts  will  be  best  met  by  the  application 
of  the  ice-bag.  If  this  does  not  suffice,  then  opium  may  be  employed. 
Reduction  of  temperature  can  be  better  effected  by  sponging  with  cool 
water,  if  agreeable  to  the  patient,  than  by  the  administration  of  antipy- 
retics, for  these  will  derange  the  stomach  and  interfere  with  the  patient 
taking  food,  a  matter  of  the  greatest  importance  in  a  disease  attended 
with  such  prostration.  The  local  application  of  guaiacol  will  often 
promptly  lower  the  temperature,  and  is  preferable,  should  such  reduc- 
tion be  thought  advisable,  to  the  administration  of  large  doses  of  quinine, 
antipyrin,  and  similar  agents.  Alcohol  is  to  be  given  freely,  in  the 
form  of  wine,  brandy,  or  whiskey ;  it  strengthens  a  weak  heart  and 
it  lessens  the  amount  of  albumin  passing  off  by  the  kidneys.  To  secure 
sleep,  sulphonal  is  advised  by  Runge,  who  states  that  chloral  is  at  all 
events  to  be  avoided.  The  abdominal  distention  may  be  temporarily 
lessened  by  using  a  rectal  tube,  passed  high  up,  permitting  the  escape  of 
gas  through  it,  or  by  the  injection  into  the  rectum  of  oil  of  turpentine 
in  suitable  mixture.  The  constipation  is  relieved  by  a  laxative  injec- 


668  THE  PATHOLOGY  OF  THE  PUERPERAL  STATE. 

tion ;  especially  must  active  purgation  be  avoided.  The  vomiting  is 
treated  by  ice-cold  drinks  containing  carbonic  acid.  Kalteubach  has 
suggested  washing  out  of  the  stomach  as  rational  treatment,  on  the 
ground  that  partly  through  this  organ  a  ptomaine  or  toxalbumin  is 
probably  eliminated. 

The  treatment  of  septicaemia  by  opium  is  now  regarded  with  little 
favor.  Nevertheless,  it  counted  able  advocates  and  undoubted  suc- 
cesses. In  1848  the  late  Dr.  Alonzo  Clark  first  applied  the  opium 
treatment,  which  he  had  employed  from  1841  to  peritonitis  from  in- 
testinal perforation,  to  puerperal  peritonitis  with  success.  The  follow- 
ing is  an  extract  from  a  letter  written  me  in  1876  by  Dr.  Clark  :l 

"  Regarding  the  rules,  I  begin  with  two  grains  of  opium,  or  its  equivalent 
opiate,  and  in  two  hours  give  the  same,  or  more  or  less,  according  to  the  effects 
produced.  Patients  resist  or  yield  to  the  narcotic  effects  of  the  drug  very  differ- 
ently. In  some  cases  twenty-four  grains  of  opium  a  day  are  all  that  is  required ; 
in  a  few,  twelve  or  sixteen  grains  are  sufficient.  In  most,  two  to  four  grains  at  a 
dose  are  needed ;  in  a  few,  more  than  this.  The  aim  is  to  get  and  maintain  the 
symptoms  of  safe  narcotism,  or,  as  I  sometimes  term  it,  semi-narcotism,  indicated 
by  subsidence  of  the  pain,  contracted  pupils,  itching  of  nose  and  skin,  a  con- 
tinuous sleep,  from  which,  however,  the  patient  is  easily  aroused,  reduced  fre- 
quency of  respiration,  followed  by  reduced  frequency  of  the  pulse,  and  absolute 
quiet  of  the  bowels.  Regarding  the  respiration,  the  aim  is  to  reduce  its  fre- 
quency to  twelve  in  the  minute,  and  in  the  attempt  to  do  this  it  is  often  found 
to  fall  as  low  as  seven  without  danger ;  if  this  occurs,  the  opium  is  then  withheld 
for  a  few  hours,  till  it  rises  to  ten,  when  a  smaller  dose  is  given,  to  be  increased 
or  not  afterward." 

Most  practitioners  do  not  use  opium,  even  in  the  treatment  of  puerperal  peri- 
tonitis, so  freely,  but  administer  it  chiefly  for  the  relief  of  pain ;  frequently  a 
hypodermatic  of  morphine  may  be  usefully  given  for  this  purpose. 

That  great  teacher,  one  of  the  greatest  of  his  day,  the  late  Dr.  Charles  D. 
Meigs,  declared,  speaking  of  the  treatment  of  a  woman  having  puerperal  fever : 
"  If  I  cannot  cure  her  by  venesection,  my  patient  may  recover  by  the  provi- 
dence of  God.  All  other  human  means  seem  to  me  to  be  useless  and  beneath 
contempt,  as  prime  remedies,  venesection  being  omitted."  But  the  practitioner 
of  to-day,  instead  of  taking,  would  try  to  make  blood.2 

PYJEMIA.  This  form  of  puerperal  fever  occurs  later  than  that  previously 
presented — usually  at  the  end  of  the  first  or  beginning  of  the  second 
week.  The  abdomen  is  flat,  no  tympanites ;  the  chill  is  not  single,  but 
multiple,  repeated  during  the  progress  of  the  disease,  so  that  there  are 
thirty  or  forty,  or  even  a  larger  number  of  chills.  In  a  patient  attended 
by  me  in  consultation  there  were  more  than  fifty  chills,  and  Ahlfeld 
states  that  in  one  of  his  cases  there  were  fifty -seven.  The  temperature 
at  one  time  may  be  104°,  and  again  become  between  the  chills  but  a 
little  more  than  normal,  or  even  quite  normal. 

The  great  increase  of  temperature,  followed  by  a  decline  with  more 
or  less  perspiration,  and  the  recurrence  of  chills  with  new  accessions  of 
fever,  led  Osiander  thus  to  speak  of  the  distinction  between  this  form 
of  puerperal  septicaemia  and  intermittent  fever : 

1  Author's  Address  on  Obstetrics,  International  Medical  Congress,  at  Philadelphia,  1876. 

2  In  one  of  Smollett's  stories  a  character  for  whom  the  doctor  has  prescribed  "  neutral  draughts," 
asserts  that  '•  they  are  so  neutral  they  declare  neither  for  the  patient  nor  for  the  disease."  This  criti- 
cism would  not  apply  to  the  treatment  of  puerperal  fever  by  bleeding ;  for,  with  the  views  of  the 
pathology  of  the  disease  now  prevailing,  such  treatment  would  be  regarded  as  declaring  for  the 
disease,  not  for  the  patient. 


PUERPERAL  FEVER, 

"This  fever  differs  from  the  common  cold  or  intermittent  fever  which  attacks 
women  in  childbirth  sometimes,  or  with  which  they  oftentimes  pass  from  preg- 
nancy into  childbed — and  which,  according  to  the  testimony  of  writers,  Torti, 
for  example,  is  always  very  dangerous,  but  which  can  generally  be  cured  by  the 
use  of  the  Peruvian  bark — in  this  respect:  at  the  time  between  the  attacks  a  real 
abatement  of  the  feverish  pulse  cannot  be  perceived,  and  the  chill  never  occurs 
at  a  definite  or  regular  time.'1 

Metastases  to  various  organs  or  parts  of  the  body  may  occur — the 
liver,  spleen,  kidneys,  thyroid,  lungs,  mammary  gland  ;  to  the  eye,  caus- 
ing panophthalmitis  ;  to  the  connective  tissue,  to  joints,  etc.  A  singular 
fact,  and,  I  believe,  as  yet  without  satisfactory  explanation,  is,  that  if  a 
joint  of  one  of  the  lower  limbs  is  affected  it  is  the  right  knee  oftener 
than  any  other.  After  metastases  occur  the  fever  is  usually  continuous. 

The  frequent  chills,  the  absence  of  abdominal  swelling,  the  repeated 
and  great  variations  in  temperature,  aud  the  absence  of  all  indications 
of  peritoneal  inflammation,  and,  finally,  the  occurrence  of  metastases, 
would  prevent  confounding  pysemic  with  septicsemic  infection. 

While  the  prognosis  is  serious,  it  is  not  so  grave  as  in  septica3mia. 
The  treatment  is  symptomatic.  Chills  are  met  by  hot  drinks,  usually 
containing  whiskey,  brandy,  or  wine.  Antipyretics  are  of  no  value  in 
high  temperatures ;  the  reduction  of  the  heat  will  soon  spontaneously 
occur,  and  the  medicines  employed  may  produce  disorder  of  the  stomach, 
lessening  even  the  ability  to  take  food.  One  of  the  best  authorities 
has  recently  stated,  that  upon  good  nutrition,  careful  nursing — especially 
protecting  parts  subjected  to  continued  pressure  from  bedsores,  pre- 
venting active  movements  lest  emboli  may  thus  be  detached  from  throm- 
bosed  veins — and  alcoholic  stimulants  as  occasion  may  require,  the  hope 
of  recovery  will  rest  rather  than  on  the  administration  of  drugs.  Kal- 
tenbach  has  advised,  in  great,  continued  frequency  of  the  pulse, 
tincture  of  aconite  or  infusion  of  digitalis,  and  in  severe  heart  weakness 
preparations  of  coffee  by  the  mouth  and  hypodermatic  injections  of  ether, 
tincture  of  musk,  and  oil  of  camphor.1  If  a  joint  is  affected,  at  first  let 
it  be  made  immobile ;  suppuration  occurring,  evacuation  of  the  pus ; 
after  the  fever  is  gone,  and  all  acute  symptoms  of  the  affection  have 
disappeared,  massage  and  passive  movements  of  the  joint  must  be  em- 
ployed to  reduce  the  swelling  and  to  prevent  the  temporary  anchylosis 
from  becoming  permanent.  At  this  stage,  too,  relief  from  pain  and 
swelling  will  be  obtained  by  successive  small  blisters  of  cantharidal  col- 
lodion. « 

The  patient  must  remain  in  bed  for  two  weeks  after  the  fever  has 
disappeared. 

SURGICAL  TREATMENT.  The  removal  of  tubes  containing  pus  has 
several  times  been  successfully  done  in  puerperal  women.  Nevertheless, 
knowing  that  pyosalpinx  is  not  a  frequent  manifestation  of  puerperal 
infection,  and  bearing  in  mind  the  researches  of  Bumm,  previously  re- 
ferred to,  showing  the  barrier  presented  by  the  uterine  ends  of  the  tubes 

1  Leyden  (Deutsch.  med.  Wochenschrift,  January,  1894)  states  that  in  severe  cases  of  puerperal 
sepsis  cardiac  manifestations  are  not  rare,  chiefly  weakness,  finally  paralysis.  This  is  explained 
as  due  to  the  action  of  a  toxic  substance  upon  the  heart,  this  substance  produced  from  the  rapid 
development  of  septic  bacteria,  chiefly  streptococci,  more  rarely  staphylococci.  The  autopsy  of  a 
case  of  fatal  infection  showed  a  very  pale  neart,  no  fatty  degeneration  of  the  muscle,  but  dilata- 
tion of  the  left  ventricle. 


670      THE  PATHOLOGY  OF  THE  PUERPERAL  STATE. 

to  the  progress  of  the  infection  in  septic  endometritis,  so  that  the  poison 
traverses  the  uterine  wall,  and  only  gets  access  to  the  tubes  by  their 
abdominal  openings,  it  may  be  questioned  whether  in  many  of  these 
cases  the  infection  was  puerperal,  and  the  purulent  collections  possibly 
antedated  the  pregnancy.  Be  this  as  it  may,  encysted  collections  of 
pus,  whether  tubal  or  not,  found  in  connection  with  puerperal  infection, 
should  be  removed.  Further,  success  may  reasonably  be  expected  in 
case  of  purulent  peritonitis,  from  abdominal  section,  removal  of  the  pus, 
washing  out  and  disinfecting  the  abdominal  cavity.  But  in  general  septic 
peritonitis  the  hope  is  vain  from  this  treatment.  Removal  of  the  uterus  in 
pysemic  infection  has  little  to  promise,  and  probably  were  all  the  cases 
in  which  this  operation  has  been  done  reported,  the  number  of  successes 
would  be  small.  Unfortunately,  too,  in  many  instances  reported  of 
hysterectomy  for  the  removal  of  an  infecting  centre,  there  fail  the  per- 
fect clinical  history  and  the  careful  microscopic  examination  demon- 
strating the  essential  nature  of  the  disorder. 

Dr.  Parish1  has  published  a  most  instructive  case  of  successful  abdom- 
inal section  for  uterine  lymphangitis,  the  infection  being  plainly  septi- 
caemic,  not  pysemic. 

He  was  called  to  the  patient  the  third  week  of  her  lying-in,  and  the  following 
is  the  description  of  his  operation :  "  I  opened  the  abdomen  in  the  median  line, 
under  aseptic  precautions.  After  dissecting  up  adhesions  I  found  the  ap- 
pendages of  both  sides  free  from  pus.  The  uterus  presented  a  bilobed  appear- 
ance, with  a  nearly  median  vertical  groove.  The  right  lobe  was  doughy  to  the 
touch,  without  fluctuation,  and  of  a  dark-purplish  color.  Around  it  the  exu- 
date  and  adhesions  had  been  arranged.  On  puncturing  this  part  of  the  uterus 
about  two  ounces  of  pus  escaped.  The  abscess  cavity  presented  irregular, 
ragged  walls,  and  did  not  communicate  with  the  uterine  cavity.  I  now  secured 
the  uterine  and  ovarian  arteries  of  one  side  by  tying  off  the  broad  ligament  at 
its  base  and  at  its  pelvic  extremity.  Thus,  by  two  semi-elliptical  incisions  in  the 
uterus,  longitudinal  in  direction,  and  extending  from  near  the  neck  to  the  fundus, 
one  behind,  the  other  in  front  of  the  uterine  end  of  the  broad  ligament,  I  re- 
moved a  wedge-shaped  portion  of  the  uterus,  including  within  the  wedge  the 
connection  of  the  broad  ligament  and  the  walls  of  the  uterine  abscess.  These 
incisions  did  not  reach  the  uterine  cavity.  Numerous  lymphatics  about  the  ab- 
scess showed  on  section  pus  within  their  calibres,  as  I  have  repeatedly  seen  in 
autopsies  on  women  dead  of  lymphatic  septicaemia.  Several  thin  sections  were 
now  removed  from  the  incised  portions  of  the  uterus  until  more  nearly  healthy 
uterine  tissue  was  reached  ;  I  then  drew  together  the  lips  of  the  uterine  wound 
with  silk  sutures." 

It  is  not  necessary  to  continue  the  further  narrative  given  by  Dr. 
Parish,  and  there  will  only  be  added  that  the  patient  made  a  satisfactory 
recovery.  As  a  pioneer  operation  and  wise,  it  is  worthy  of  this  addi- 
tional record,  and  of  just  commendation.  Future  experience  must  de- 
cide whether  the  field  of  surgery  in  puerperal  infection  ought  to  be 
enlarged  or  lessened. 

ULCERATIVE  ENDOCARDITIS.  This  is  the  most  serious  manifesta- 
tion of  puerperal  poisoning,  and  occurs  more  frequently  in  pysernia  than 
in  septicaemia,  while  in  some  cases  the  two  modes  of  infection  may  be 
present — that  is,  a  septicopysemia.  It  is  almost  always  restricted  to  the 
left  heart,  and  depends  upon  micrococci ;  the  streptococcus,  staphylo- 

1  Transactions  of  the  American  Gynecological  Society,  1892. 


PUERPERAL  FEVER.  671 

coccus,  and  the  diplococcus  of  pneumonia  have  been  demonstrated.  The 
disease  usually  not  appearing  before  the  second  week,  begins  with  a 
chill,  followed  by  severe  fever,  the  temperature  104°  or  higher,  the 
pulse  from  130  to  160,  small,  easily  compressed,  and,  according  to 
Olshausen,  frequently  dicrotic.  Chills  continue.  Retinal  hemorrhage 
is  found  in  80  per  cent.,  and  cerebral  disorder  may  occur;  the  patient 
complains  of  violent  headache,  is  restless,  and  cannot  sleep,  possibly  be- 
comes delirious.  Meningitis  is  not  uncommon. 

The  diagnosis  of  ulcerative  endocarditis  is  made  by  the  frequency  of 
the  pulse,  and  its  weakness,  by  a  loud  systolic  murmur  heard  over  the 
aorta  and  over  the  mitral,  by  the  frequent  chills,  and  by  the  condition 
of  the  eyes. 

The  patient  usually  lives  more  than  a  week,  but  death  is  inevitable, 
and  hence  the  treatment,  which  will  be  symptomatic,  can  only  palliate. 

PROPHYLAXIS.  Concluding  this  chapter  upon  the  chief  forms  of 
puerperal  infection  and  their  treatment,  and  having  seen  that  in  some 
of  these  therapeutics  may  completely  fail,  let  the  importance  of  pre- 
vention be  more  deeply  impressed  on  the  obstetrician's  mind.  A  few 
years  ago  a  distinguished  British1  obstetrician  suggested  that  "  through 
an  extended  study  of  microbiology  and  of  organic  chemistry  we  may 
hope  to  become  possessed  of  means  which  will  destroy  pathogenic 
microbes  in  the  body  without  damaging  the  patient,  and  thus  cure 
puerperal  fever."  But  even  if  that  day  should  come,  the  duty  of  pre- 
venting puerperal  fever  by  strictest  asepsis  and  judicious  antisepsis 
must  always  remain,  and  still  more  imperative  is  the  duty  before  its 
coming. 

i  James  Watt  Black,  M.D. :  Inaugural  Address  as  President  of  the  London  Obstetrical  Society, 
1891. 


CHAPTER   XVII. 

SUDDEN   DEATH   IN,   OR   AFTER    LABOR — DISEASES   OF  THE 

NEWBORN. 

SUDDEN  DEATH  IN,  OR  AFTER  LABOR.  Whether  one  believe,  with 
the  Roman  Emperor,  that  the  death  which  is  most  sudden  is  that  most 
to  be  desired,  or  place  it,  as  is  done  in  the  rubric  familiar  to  all,  at  the 
climax  of  earthly  calamities,  this  event  is  always  startling  and  usually 
most  painful  to  the  witnesses.  The  pain  is  greatest,  the  misfortune 
almost  without  exception  the  gravest,  if  a  mother  dies  in  childbirth 
or  soon  after.  Many  causes  conspire  to  make  the  event  peculiarly  sad. 
The  abrupt  severing  of  new  ties,  the  loss  of  life  in  giving  life,  and  the 
sharp  contrast  between  an  infant  living  and  a  mother  perishing  just 
when  the  former  so  needs  her  loving  care,  are  among  these  causes. 

The  obstetrician  not  infrequently  suffers  public  reproach  when  such 
an  event  occurs  in  his  practice,  for  people  are  slow  to  understand  how 
that  which  is  in  the  majority  of  cases  a  simple  physiological  process 
may  have  a  fatal  issue.  Moreover,  in  some  instances  death  can  be 
averted  if  the  practitioner,  forewarned  of  its  imminence,  uses  appro- 
priate means  ;  in  others  the  prophecy  of  such  event  as  possible,  probable, 
or  inevitable  may  protect  his  reputation  ;  and  in  still  other  cases,  if 
prophecy  should  fail — the  event,  casting  no  shadow  before  it,  coming 
unexpectedly  to  him  as  to  others — his  ability  to  explain  its  cause  is  very 
important.  It  is  therefore  alike  his  duty  and  interest  to  know  the 
usual  causes  of  sudden  death  in  childbirth  or  after  it. 

Constant  supply  of  oxygen  to  the  organism  and  the  regular  distribu- 
tion of  blood  suitable  for  nutrition  are  the  two  essentials1  for  the  main- 
tenance of  life  ;  in  other  words,  the  lungs  and  the  heart  must  perform 
their  respective  functions,  and  thus  the  tripod  of  Bichat  is  replaced  by 
a  biped,  for  the  brainless  fowl  lives,  though  it  instantly  perishes  if  de- 
prived of  heart  or  lungs.  In  most  cases  of  sudden  death  the  heart,  the 
ultimum  moriens  of  Galen,  first  stops,  or,  in  other  words,  death  is  caused 
by  syncope,  not  by  asphyxia.  If  death  begins  at  the  lungs,  the  fatal 
event  is  usually  slow  in  progress ;  nevertheless,  it  may  then  in  some 
instances  be  sudden,  as  from  pulmonary  embolism,  just  as,  on  the  other 
hand,  cardiac  death  does  not  always  occur  even  rapidly.  In  still  other 
cases  lungs  and  heart  may  both  fail,  the  failure  of  neither  being  the 
exclusive  cause  of  death. 

Death  from  /Syncope.  The  fact  that  syncope  may  be  caused  by  a 
strong  mental  impression,  as  fear,  anger,  joy,  or  sorrow,  is  familiar  to 
the  profession  as  well  as  to  the  public.  A  reasonable  supposition  is  that 

1  Strauss :  Nouveau  Diclionnaire  de  Medecine  et  de  Chirurgie  pratiques,  t.  xxxiv. 


SUDDEN  DEATH  IN  OR  AFTER  LABOR.  673 

in  such  cases  the  impression  upon  the  brain  is  first  reflected  to  the  bulb, 
then  probably  through  the  pneumogastric  nerves  the  bulb  itself  arrests 
the  action  of  the  heart,  and  hence  the  sudden  paleness,  the  cerebral 
anaemia,  and  the  syncope.1  Wundt,  adopting  Kant's  classification  of 
emotions  into  sthenic  and  asthenic,2  says  that  the  former  kill  by  apo- 
plexy, and  the  latter  by  cardiac  paralysis,  or  rather  by  the  interruption 
of  cardiac  function  which  energetic  aud  persistent  excitement  of  the  in- 
hibitory nerves  of  the  heart  causes. 

The  greater  nervous  susceptibility  of  woman  than  of  man,  and  its 
notable  increase  during  pregnancy,  would  explain  the  special  liability 
she  then  has  to  be  injuriously  affected  by  a  profound  emotion,  whether 
of  pain  or  of  pleasure. 

Chevallier  has  narrated  cases  of  sudden  death  occurring  to  puerperse  which  he 
attributed  to  idiopathic  asphyxia.  But,  as  remarked  by  McClintock,3  "  some 
very  competent  authorities  look  upon  the  mortal  affection  described  by  M. 
Chevallier  as  merely  a  form  of  syncope."  Undoubtedly  the  later  term  is  the 
correct  one.  It  is  remarkable  that  several  of  the  cases  adduced  were  those  in 
which  death  followed  a  strong  emotion ;  in  other  words,  they  were  instances 
of  fatal  emotive  syncope.  One  of  these,  for  example,  taken  from  Morgagni,  was 
that  of  a  multipara,  who,  after  an  easy  labor,  was  delivered  of  a  girl,  her  husband 
and  she  both  being  desirous  of  a  boy  ;  the  sex  of  the  child  was  imprudently  told 
her;  she  was  affected  with  such  deep  sorrow  that  her  pulse  became  weak  and 
her  skin  cold,  and  in  a  few  hours  she  died ;  the  autopsy  presented  no  satisfactory 
cause  of  the  fatal  result. 

Winckel4  refers  to  strong  mental  emotion,  especially  severe  suffering, 
as  a  cause  of  sudden  death,  and  states  that  Baart  de  la  Faille  has  col- 
lected 13  cases  of  post-partum  collapse  in  which  neither  embolism  nor 
the  entrance  of  air  was  probable,  but  in  which,  however,  the  entire 
complexus  of  symptoms  had  very  great  similarity  to  cardiac  paral- 
ysis. 

Dr.  Lusk5  lost  a  primipara  two  hours  after  delivery  with  forceps,  and 
he  attributed  the  death  to  "  nerve-exhaustion  and  shock."  Dr.  Fayette 
Dunlap,6  in  the  case  of  a  patient  dying  a  few  hours  after  the  termina- 
tion of  her  labor,  regarded  exhaustion  as  the  cause  of  the  unhappy 
event. 

1.  Death  may  be  Caused  by  Pulmonary  Embolism.  A  thrombosis 
having  formed  in  uterine,  pelvic,  or  femoral  vein,  an  embolus  is  de- 
tached, and  passing  to  the  right  heart  is  arrested  in  the  pulmonary 
artery.  The  most  frequent  instances  of  this  accident  have  been  ob- 
served in  patients  suffering  with  phlegmasia  alba  dolens. 

The  unhappy  victim  may  take  the  erect  or  sitting  position  after  hav- 
ing been  recumbent  for  days  or  weeks,  or  make  other  slight  exertion, 
and  death  come  suddenly  as  if  from  a  thunderbolt. 

The  death  may  be  caused  by  embolism  just  after  labor  as  a  conse- 
quence of  artificial  thrombosis  in  a  uterine  vessel.  Herman  and  Brown 
have  reported  the  following  case :  An  intra-uterine  injection  of  a  solu- 
tion of  perchloride  of  iron  was  used  for  post-partum  hemorrhage,  and 

1  Strauss,  op.  cit.  2  Elements  of  Physiological  Psychology . 

3  Dublin  Medical  Press,  1852.  «  Lehrbuch  der  GeburtshUlfe. 

5  Journal  of  the  American  Medical  Association,  1884.  6  Ibid.,  18«7. 

43 


674  THE  PATHOLOGY  OF  THE  PUERPERAL  STATE. 

the  woman  died,  the  death  being  attributed   to  an  embolus  from  a 
thrombus  in  the  uterine  vein.1 

2.  Death  may  be  Caused  by  the  Entrance  of  Air  into  the  Uterine  Veins. 
A  patient  of  Olshausen2  was  having  used  while  she  was  in  labor  a 
uterine  douche  to  hasten  etfacement  of  the  cervix ;  she  complained  of 
pain,  raised  herself  up  in  bed,  gave  some  deep  inspirations,  and  died  in 
a  minute.  At  the  autopsy,  made  eight  hours  after  death,  bubbles  of  air 
were  found  in  the  cardiac  vessels,  in  the  uterine  veins,  and  in  the  in- 
ferior vena  cava.  In  Litzmanu's  case  four  uterine  douches  were  given 
with  Mayer's  pump  to  induce  premature  labor;  suddenly  the  woman 
became  livid  and  died  in  a  few  seconds.  The  post-mortem,  made  six- 
teen hours  after  death,  showed  bubbles  of  air  in  the  uterine  veins  and 
in  the  ovarian  and  renal  plexuses. 

Gunz  has  reported  the  case  of  a  girl  twenty  years  of  age  who  was  found  dead 
in  her  room,  having  between  her  limbs  an  irrigator,  the  canula  being  in  the 
vagina.  She  was  found  to  be  three  months  and  a  half  pregnant,  and  death 
was  shown  to  have  resulted  from  the  entrance  of  air  into  the  veins,  the  canula 
having  penetrated  the  cervical  canal.  Spontaneous  entrance  of  air  is  illustrated 
by  the  following  case :  A  secundipara,  twenty-five  years  of  age,  was,  after  an  easy 
labor,  delivered  of  her  child  while  lying  upon  her  side;  she  was  then  turned 
upon  her  back,  gentle  massage  used,  and  the  placenta  was  expelled.  The  face 
suddenly  became  livid,  the  respiration  labored,  the  pulse  weak;  after  vomiting 
a  little  mucus  and  after  slight  convulsive  movements  she  became  collapsed  and 
died.  At  the  autopsy  the  uterus  was  found  as  large  as  the  head  of  a  child,  and 
its  walls  relaxed.  In  compressing  the  posterior  wall  and  the  fundus  of  the  uterus 
at  the  place  where  the  placenta  had  been  attached  fine  crepitation  was  heard  ; 
when  the  organ  was  thrown  into  water  a  great  number  of  small  bubbles  of  air 
escaped.  The  parts  of  the  uterus  near  the  cervix  did  not  appear  to  contain  air, 
nor  did  the  veins  of  the  broad  ligament,  the  ovarian  veins,  or  the  vena  cava. 

Another  instance  is  the  following:  Cordwenthas  given3  the  history  of  a  prim- 
ipara,  twenty-eight  years  old,  who  was  delivered  while  standing,  of  a  living 
male  child,  which  fell  to  the  floor,  dragging  the  placenta  and  membranes  with  it. 
A  "gurgling  "  was  heard  by  the  attendants,  and  the  woman  died  almost  imme- 
diately. At  the  post-mortem  air  was  found  in  the  uterine  wall  at  the  fundus,  in 
the  coronary  vein,  and  in  the  right  heart. 

Winckel/  in  referring  to  the  entrance  of  air  into  the  uterine  veins  as  a  cause 
of  sudden  death,  remarks  that  in  an  examination  during  labor,  in  the  removal 
of  the  placenta  from  the  vagina,  in  the  introduction  of  the  hand  into  the  uterus 
for  the  purpose  of  removing  the  placenta,  the  entrance  of  air  is  almost  in- 
evitable, and  that  sometimes  the  contained  air  escapes  with  a  quite  audible 
sound.  He  also  refers  to  the  fact  that  if  the  os  uteri Ibe  closed  and  decomposi- 
tion of  retained  material  occur  in  the  cavity,  gas  may  enter  the  circulation. 

Frendenburg  states  that  in  six  years  at  the  Berlin  Klinik  there  were  three 
deaths  from  air  entering  veins  in  placenta  prsevia ;  instances  of  fatal  air-embo- 
lism during  the  application  of  an  iodoform-gauze  tampon  for  hemorrhage  have 
been  observed. 

Lauffs5  has  collected  43  cases  of  air  entering  the  uterine  veins.  In 
17  the  accident  was  caused  by  injections  into  the  birth-canal,  18  were 
spontaneous,  and  8  resulted  from  the  formation  of  gas  in  the  uterus ; 
39  of  the  43  were  fatal,  and  the  presence  of  air  was  proved  by  the 
autopsy  in  31. 

1  Obstetrical  Journal  of  Great  Britain  and  Ireland,  January,  1880. 

2  For  these  cases  see  Braun  on  •'  Sudden  Death  from  the  Entrance  of  Air  into  the  Uterine  Veins," 
Wien.  med.  Woch.,  1883. 

a  St.  George's  Hospital  Reports,  London.  1873.  4  Op.  cit. 

6  Ueber  Eintritt  von  Luft  in  die  Venen  der  Gebarmutter  bei  und  nach  der  Geburt.,  Bonn,  1885. 


SUDDEN  DEATH  IN  OR  AFTER  LABOR. 

The  presence  of  air  in  the  veins  in  an  autopsy  does  not  prove  death 
from  air-embolism,  for  Welch  and  Nuttall  have  shown1  that  this  may 
originate  from  a  gas-producing  bacillus,  bacillus  aerogenes  capsulatus,  as 
named  by  them.  Graham2  also  described  a  case  in  which  this  bacillus 
was  proved  to  be  present ;  and  Ernst3  has  made  a  thorough  study  of  the 
subject.  Nevertheless,  the  suddenness  of  the  death  from  air-embolism 
would  be  sufficiently  characteristic. 

3.  Death  may  Result  from  Some  One  of  the  Accidents  of  Labor.    These 
accidents  have  already  been  considered,  and  it  is  hardly  necessary  tore- 
mind  the  reader  that  hemorrhage,  rupture  or  inversion  of  the  uterus,  or 
eclampsia,  may  cause  sudden  death. 

4.  Different  Diseases  may  Cause  Sudden  Death.     Among  these  may 
be  mentioned  rupture  of  an  aneurism  or  of  the  heart,  having  under- 
gone fatty  degeneration,  cerebral  or  pulmonary  apoplexy,  pulmonary 
emphysema,  haemoptysis,  rupture  of  the  spleen,  rupture  of  an  hepatic 
abscess,  and  haematemesis. 

DISEASES  OF  THE  NEWBORN.  Sclerema  Neonatorum.  The  follow- 
ing is  the  definition  given  by  Ballantyne4  of  this  affection  :  A  grave 
disease,  occurring  almost  always  in  the  newborn  infant,  characterized  by 
induration  and  sometimes  by  oedema  of  the  subcutaneous  cellular  tissue, 
and  by  lowering  of  the  body-temperature,  and  due  possibly  to  some 
trophic  lesion  of  the  nervous  system.  Ahlfeld  regards  the  cause  as 
probably  being  in  an  interference  with  the  circulation  from  deficient 
activity  of  the  muscular  respiratory  apparatus  and  pulmonary  atelec- 
tasis.  The  disease  is  usually  fatal,  death  generally  preceded  by  a  dis- 
charge of  bloody  serum  from  the  mouth  and  nose. 

Hot  baths,  hot  wraps,  massage  from  -the  periphery  to  the  centre,  ex- 
citing strong  crying,  in  order  to  promote  the  circulation,  and  Auvard's 
couveuse,  have  been  recommended  in  the  treatment  of  sclerema. 

Diseases  of  the  Umbilicus.  Suppuration  may  occur  after  the  umbil- 
ical cord  has  fallen  off.  Kaltenbach  recommended  washing  with  3 
per  cent,  solution  of  boric  acid,  or  dusting  with  salicylic  acid  and 
starch,  1:3.  I  have  in  some  cases  employed  washing  with  alum-water 
and  then  pencilling  with  the  compound  tincture  of  benzoin. 

Abundant  granulations  may  spring  from  the  surface  to  which  the 
cord  was  attached — the  so-called  umbilical  fungus — and  give  rise  to 
abundant  secretion,  and  sometimes  bleeding  occurs.  Burnt  alum  I 
have  generally  found  sufficient  to  destroy  the  growth  ;  some  advise 
nitrate  of  silver,  or  even  nitric  acid. 

Erysipelas,  beginning  at  the  navel,  and  thence  extending  over  part 
of  the  body,  is  sometimes  seen  in  the  newborn.  The  only  instances  in 
which  I  have  observed  this  were  in  children  whose  mothers  were  suffering 
from  septic  infection,  and  the  disease  was,  without  exception,  fatal, 
convulsions  generally  occurring.  Facial  erysipelas  may  occur  in  the 
newborn,  but  it  is  less  grave  than  the  variety  mentioned. 

Instead  of  this  manifestation  of  disease  derived  from  the  sick  mother, 
there  may  occur,  from  the  entrance  of  streptococci  through  the  navel 

1  Bulletin  Johns  Hopkins  Hospital,  July-August,  1892. 

2  Columbus  Medical  Journal,  August,  1893. 

3  Virchow's  Archiv,  1893. 

4  Diseases  of  the  Foetus,  vol.  ii. 


676  THE  PATHOLOGY  OF  THE  PUERPERAL  STATE. 

wound,  either  lymphatic  or  pysemic  infection ;  in  the  one  case  peri- 
tonitis and  pleuritis,  and  in  the  other  abscesses  in  the  liver  and  throm- 
boses result. 

The  fatal  result  of  this  infection  emphasizes  the  importance  of  anti- 
septic treatment  of  the  cord,  and  of  the  immediate  removal  of  the  child 
to  another  room  if  the  mother  should  manifest  serious  infection  ;  the 
child  should  then,  too,  have  another  nurse  than  the  one  who  cares  for 
the  mother. 

After  the  disease  has  occurred  treatment,  as  Winckel  says,  only  pal- 
liates, does  not  cure. 

Tetanus  sometimes  occurs  in  the  newborn,  the  poison  of  Nicolaier's 
bacillus — tetanin — entering  most  probably  through  the  umbilical  wound. 
Since  the  discovery  of  this  bacillus  and  the  establishment  of  the  etiology 
of  the  disease  some  doubt  may  be  expressed  as  to  its  originating  from 
hot  baths. 

Ahlfeld  repeats  the  fact,  published  several  years  ago,  that  a  midwife,  out  of 
380  infants  delivered  by  her  in  the  years  1864  and  1865,  had  99  attacked  by 
tetanus;  the  cause  of  the  disease  was  supposed  to  be  the  very  hot  baths  she 
employed  in  washing  the  newborn. 

The  disease  has  been  observed  more  frequently  in  hot  climates ;  but 
here,  as  in  puerperal  tetanus,  the  fact  is  explained  by  the  want  of 
cleanliness  rather  than  the  character  of  the  climate. 

Turner,1  in  a  recent  paper  entitled  "  The  Scourge  of  St.  Kilda,"  refers  to  the 
great  mortality  from  tetanus  neonatorum  in  that  island,  quoting  in  illustration  the 
statement  made  by  Dr.  Arthur  Mitchell  in  the  Edinburgh  Medical  Journal,  1865  : 
"  Out  of  125  children,  the  offspring  of  the  fourteen  married  couples  residing  upon 
the  island  in  1860,  no  less  than  84  died  within  the  first  fourteen  days  of  life — or, 
in  other  words,  67.2  per  cent." 

In  recent  years  this  mortality  has  disappeared  in  consequence  of  antiseptic 
dressing  of  the  cord.2  Turner  alludes  in  his  paper  to  loretin,  a  new  preparation 
of  iodine,  odorless  and  not  poisonous,  as  a  very  efficient  germicide,  1  to  1000 
destroying  pathogenic  bacteria.  It  must  be  remembered,  however,  that  the  bacil- 
lus of  tetanus  has  remarkable  vitality. 

The  disease  is  first  manifested  about  the  time  the  cord  is  detached,  or 
within  a  few  days  after.  Probably  the  physician's  attention  will  first 
be  called  to  the  fact  that  the  infant  does  not  nurse,  and  upon  examina- 
tion he  finds  trismus,  though  before  this  symptom  there  may  be  observed 
restlessness,  and  trembling  of  the  lower  jaw.  Opisthotonos  follows,  the 
temperature  rises — 109.4°,  according  to  Winckel — and  the  child  soon 
perishes,  usually  from  exhaustion. 

Chloral  may  be  given,  chloroform  inhalation  used,  and  endeavor 
made  to  maintain  the  nutrition3  by  suitable  rectal  injections.  But  these 
means  only,  as  a  rule,  delay  death,  do  not  cure  the  disease.  There  may 
be  hope,  as  in  puerperal  tetanus,  from  hypodermatic  injection  of  serum 
from  an  animal  rendered  immune  to  tetanus. 

1  Glasgow  Medical  Journal,  March,  1895. 

2  Dr.  A.  0.  Kellogg,  of  Portage,  Wisconsin,  has  recently  Invented  a  very  useful  instrument  for 
applying  a  rubber  ring,  instead  of  the  ordinary  ligation  of  the  cord,  furnishing  a  perfect  safeguard 
against  hemorrhage,  and,  at  the  same  time,  the  rubber  being  made  aseptic,  may  facilitate  the 
antiseptic  treatment  of  the  cord. 

s  Papiewski  (Jahresbericht  Uber  die  Fortschritte  auf  dem  Gebiete  der  Geburtshilfe  und  Gynako- 
logie,  1894)  gives  12  cases  of  the  disease  observed  in  the  Kinderklinik  at  Gratz,  10  dying  and  2  re- 
covering ;  and  he  states  that  the  disease  with  a  short  incubation  stage,  one  to  five  days,  is  abso- 
lutely fatal. 


DISEASES  OF  THE  NEWBORN.  677 

Nearly  two  years  ago,  in  consultation  with  Dr.  W.  M.  Angney,  of  this  city, 
I  saw  a  case  of  tetanus  in  an  infant  eight  days  old.  Attention  was  directed  to 
the  disease  by  the  fact  that  the  child  could  not  nurse,  and  the  cause  was  found 
in  well-marked  trismus.  Under  the  use  of  different  remedies,  chiefly  chloral, 
and  nourishment  given  by  the  rectum,  there  was  a  temporary  improvement,  but 
death  occurred  on  the  eleventh  day.  The  nurse  was  far  from  being  cleanly  in 
her  habits,  and  probably  the  infection  occurred  from  her  improper  care  of  the 
umbilical  stump. 

Umbilical  hernia  may  sometimes  be  successfully  treated  by  strapping ; 
the  best  method  of  strapping  is,  not  by  adhesive  or  isinglass  plaster, 
but  taking  two  narrow  strips  of  mull,  fastening  one  end  of  each  by 
collodion,  and  then  reducing  the  protrusion,  passing  them  over  it  in 
the  form  of  a  Greek  cross ;  next  the  free  ends  are  similarly  fastened  by 
collodion ;  this  permits  the  application  of  antiseptic  solutions,  if  required, 
through  the  middle  portion  of  the  strips. 

Gonorrhoea  may  cause  inflammation  of  the  eyes  of  the  newborn, 
and  also,  though  very  rarely,  vulvitis  and  vagiuitis,  and  still  more 
rarely  it  causes,  according  to  Dohrn  and  Rosinski,  inflammation  of  the 
mouth. 

The  first  affection  even  is  not  frequent.  Its  prophylaxis,  so  far  as  a 
vaginal  injection  of  corrosive  sublimate  for  the  mother,  has  been  stated 
on  page  290,  and  so  far  as  it  relates  to  the  infaut,  Crede's  method — 
the  use  of  nitrate  of  silver — is  found  on  page  290.  Kaltenbach  stated 
that  by  the  employment  of  the  former,  that  is,  the  vaginal  injection  of 
corrosive  sublimate,  and  washing  the  eyes  of  the  infant  with  water  free 
from  germs,  he  had,  both  in  Giessen  and  Halle,  absolutely  good  results. 
It  is  very  important  that  in  washing  the  eyes  of  the  newborn  the  water 
employed  in  washing  the  body  should  never  be  used. 

That  the  conjunctival  inflammation  is  probably  gonorrhoeal  may  be 
assumed  from  the  fact  that  the  mother  at  the  time  of  labor  was  suffer- 
ing from  a  purulent  discharge,  that  the  inflammation  appeared  from  the 
third  to  the  fourth  day  (according  to  Kaltenbach,  the  lids  are  red  and 
swelled  even  the  second  day),  and  that  it  is  quite  severe ;  the  positive 
proof  could  only  be  had  by  examination  of  the  secretion  with  the  micro- 
scope, and  therein  finding  the  gonococcus. 

The  treatment  will  be  thoroughly  washing  away  the  purulent  secre- 
tion with  warm  water,  the  application  of  a  solution  of  nitrate  of  silver, 
one  to  two  grains  to  the  ounce,  and  then  alight  compress  which  has  been 
dipped  in  a  3  per  cent,  solution  of  boric  acid  is  applied,  and  over  this  ice. 
Ahlfeld  speaks  of  the  ice-treatment  as  absolutely  certain,  but  it  must  be 
continued  day  and  night ;  from  hour  to  hour  the  lids  are  separated  and 
cleansed  by  cotton  and  distilled  water.  Beside,  if  the  mucous  membrane 
of  the  lids  is  greatly  swelled,  separation  of  these  causes  its  eversion,  and 
it  is  to  be  pencilled  with  a  ten-grain  solution  of  nitrate  of  silver,  and 
the  excess  of  the  salt  washed  away  with  a  1  per  cent,  solution  of  chlo- 
ride of  sodium. 

More  frequently  the  practitioner  will  meet  with  simple,  rather  than  specific 
conjunctivitis,  and  its  mild  form  can  usually  be  successfully  treated  with  zinc 
acetate  or  sulphate,  two  grains  to  the  ounce  of  rose-water,  applied  once  or  twice 
a  day ;  but  he  should  remember  that  any  such  application  must  be  thorough, 
so  that  the  solution  may  be  diffused  over  the  entire  surface  diseased. 


678  THE  PATHOLOGY  OF  THE  PUERPERAL  STATE. 

Gonoirhceal  vulvitis  and  vaginitis  is  explained  by  Ahlfeld  as  resultiug 
from  the  mother,  the  wet-nurse,  or  the  nurse  in  washing  the  infant 
bringing  gonorrhoea!  matter  in  contact  with  the  parts.  The  treatment 
is  by  corrosive  sublimate,  1  part  to  5000. 

Acute  hcemoglobinuria,  known  also  as  Winckel's  disease,  because  he 
first  proved  its  character,  is  rare.  The  disease  is  manifested  by  cyanosis, 
jaundice,  and  hemorrhages  from  various  organs.  A  fatal  result  usually 
occurred  in  thirty-two  hours ;  nineteen  out  of  twenty-three  cases  seen 
by  him  died. 

Melcena  neonatorum  designates  a  disease  of  the  newborn  character- 
ized by  discharge  of  blood  from  the  stomach  and  from  the  bowels ;  in 
some  cases  only  the  latter  occurs.  Of  course,  those  cases  in  which  the 
mother's  nipple  bleeds  in  nursing,  the  blood  being  swallowed  by  the 
child,  are  excluded.  Hergott1  states  that  the  disease  occurs  once  in  1000 
to  1500  births.  One-half  the  patients  affected  with  melsena  die,  Kalten- 
bach  has  said ;  but  Winckel  gives  eleven  cases  with  only  four  recove- 
ries. Hemophilia  has  been  found  in  some,  duodenal  ulcer  in  others ; 
embolism  of  gastric  and  duodenal  vessels,  arising  from  thrombosis  of 
the  umbilical  vein,  is  the  explanation  given  by  Landau,  and  some  attribute 
the  disease  to  infection,  the  nature  of  which  and  the  medium  of  entrance 
being  unknown. 

The  treatment  generally  recommended  is  muriated  tincture  of  iron, 
and  Winckel  suggests  a  firm  bandage  to  the  abdomen. 

Acute  fatty  degeneration  of  the  newborn,  or  Buhl's  disease,  described 
by  Buhl  in  1864,  consists  in  a  fatty  degeneration  of  the  cardiac  muscle, 
of  the  kidneys,  and  of  the  intestinal  epithelium.  Small  hemorrhages 
occur  in  various  organs,  heart,  pleura,  peritoneum,  skin,  meninges,  etc. 
Kaltenbach  refers  to  the  children  generally  being  born  asphyxiated,  and 
in  the  first  days  appearing  cyanosed,  and  later  become  jaundiced  ;  the 
infant  has  diarrhoea,  often  also  vomiting,  and  next  bleeding  from  stomach 
and  intestine,  later  from  the  navel.  Both  this  and  Winckel's  disease 
have  been  attributed  to  infection — "  perhaps  a  severe  sepsis,"  Ahlfeld 
suggest  as  the  cause  of  this  malady. 

1  Arch,  de  Tocol.  et  Gyn.,  April,  1894. 


INDEX. 


i  BDOMEN,  appearance  of,  in  pregnancy,  170 
A  discoloration  of,  in  pregnancy,  170 

increase  in  size  of,  without  enlargement 
of  the  uterus,  diagnosis  of,  from  preg- 
nancy, 205 

in  plural  pregnancy,  202 
pendulous,  486,  507 
Abdominal  contractions  in  labor,  238 
palpation  in  pregnancy,  193 
pregnancy,  368 

secondary,  368 

section  in  the  treatment  of  ectopic  preg- 
nancy, 374 

tenderness  in  puerperal  septicpemia,  667 
touch  in  pregnancy,  193 
tumors,  204 
Abortion,  231,  464 

after-treatment  of,  476 
beginning,  treatment  of,  471 
causes  of,  465 
classification  of,  465 
definition  of,  464 
frequency  of,  465 

from  causes  belonging  to  the  ovurn,  468 
from  the  use  of  medicines,  467 
historical  notice  of,  574 
indications  for,  artificial,  575 
incomplete,  473 
induction  of,  574 
in  albuminuria,  575 
inevitable  treatment  of,  471 
missed,  476 

of  maternal  origin,  466 
of  ovular  origin,  468  • 
of  paternal  origin,  466 
prognosis  of,  469 
symptoms  of,  468 
time  of  greatest  frequency,  465 
treatment  of,  470 
of  beginning,  471 
of  inevitable,  471 
prophylactic,  470 
Abscess,  mammary.  644 
treatment  of,  644 
Acardia,  165,  527 
Accidental  hemorrhage,  393 
causes  of,  393 
treatment  of,  394 
Accommodation,  250 
Accouchement,  17 
Accoucheur,  17 

articles  required  by  the,  294 
Acephalia,  527 

Acute  infectious  diseases  in  pregnancy,  427 
yellow  atrophy  of  the  liver  in  pregnancy, 

424 

treatment  of,  425 
Adipocere,  369 
After-pains,  334 
Agalactia,  350 

Albuminuria  in  pregnancy,  404 
causes,  404 
course,  404 
prognosis,  405 
symptoms,  401 
treatment,  405 
Albuminuric  retinitis,  575 
Alcohol  in  puerperal  septicaemia.  667 
Allantois,  124 
Amastia,  91 

Amenorrhoea  as  a  sign  of  pregnancy,  186 
Amnial  liquor,  126 


Amnion,  125 

anomalies  of,  457 
fluid  of,  126 
formation  of,  123 
Amniotitis,  457 

Amputations,  spontaneous  intra-uterine,  461 
Amyl  nitrite  in  eclampsia,  418 
Anaemia  in  pregnancy,  401 
causes  of,  401 
symptoms  of,  402 
treatment  of,  402 
pernicious,  in  pregnancy,  401 
Anaesthesia,  291 
history  of,  291 
general,  292 
Anencephalia,  527 
Ankylotic  obliquely  contracted  pelvis,  515 

transversely  contracted  pelvis,  513 
Anomalies  of  form  and  of  position  of  the  uterus 

in  labor,  485 
of  organs  adjacent  to  the  uterus  during  labor, 

490 

of  amnial  liquor,  457 
of  amnion,  457 

of  forces  concerned  in  labor,  477 
of  mechanism  of  labor  in  face  presentation, 

275 

in  pelvic  presentation,  280 
of  pelvis  (vide  Pelvis,  anomalies  of  the),  493 
of  soft  parts  in  labor,  485 
of  umbilical  cord,  454 
Anteflexion  of  uterus  in  pregnancy,  435 
Anteversion  of  uterus  in  pregnancy,  435 
Antipyretic  treatment  of  puerperal  septicaemia, 

667 

Antisepsis  in  labor,  289 
of  patient,  290 
of  obstetrician,  290 
Antiseptic  pads,  316 

Aorta,  compression  of,  in  post-partum  hemor- 
rhage, 562 

Appendages,  foetal,  125 
Apron,  Hottentot,  48 
Arbor  uteri  vivificans,  60 

vitse  uterina,  60 
Area  germinativa,  122 
Areola  of  mammse,  88 
in  blondes,  88 
in  brunettes,  88 
in  virgins,  88 

changes  of,  in  pregnancy,  182 
secondary,  183 
Arm,  dorsal  displacement  of,  causing  dystocia, 

537 

Arms,  ascension  of,  537 
Arteries,  ovarian,  66 

uterine,  66 

Articulations  (vide  Joints). 
Artificial  feeding  of  infants,  357 

respiration,  different  methods  of  perform- 
ing, 310 

Dew's  method,  313 
Forrest's  method,  313 
insufflation  through  a  tube  passed  into  the 

larynx,  312 

mouth-to-mouth  insufflation,  313 
Schultze's  method,  312 
Sylvester's  method,  311 
traction  of  tougue,  606 
Ascites,  diagnosis  of,  from  pregnancy,  206 

foetal,  causing  dystocia,  527 
Asphyxia  in  the  newborn,  310 


680 


INDEX. 


Asymmetrical  changes  in  the  pelvis,  r>03 

Atavism,  infantile,  161 

Atresia  of  os,  486 

Atrophy,  acute  yellow,  of  liver,  424 

Atrophy  of  the  decidua,  448 

Attitude  of  foetus  in  womb,  150 

Auscultation  in  diagnosis  of  pregnancy,  197 

in  plural  pregnancy,  203 
Axes  of  the  pelvis,  29 
Axis-traction  by  Poullet's  method,  604 


BAG  of  waters,  241 
Ballottement,  192 
Bandage,  application  of  abdominal,  after  labor, 

316 

Band  1's  ring,  180 
Barnes's  treatment  of  placenta  prsevia,  888 

bags  or  dilators,  390 
Bartbolin,  glands  of,  580 
Basilyst,  634 
Basiotripsy,  636 
Basiqtribe,  Tarnier's,  637 
Bathing  during  pregnancy,  220 

of  the  newborn  child,  309,  355 
Battledore  placenta,  137 
Bed,  preparation  of  the,  for  labor,  297 
Biestings,  342 
Bifid  uterus,  86 

Birth-canal,  genital  portion,  43 
Births,  precocious,  210 
Bladder,  calculi  in,  obstructing  labor,  492 

condition  of,  in  first  stage  of  labor.  298 

discharges  from,  of  child,  353 

distention  of,  in  pregnancy,  437 

in  the  puerperal  state,  346 

irritability  of,  during  pregnancy,  187 
Blastodermic  vesicle,  121 
Bleeding  in  eclampsia,  416 
Blot's  perforator,  633 
Blood,  changes  of,  in  pregnancy,  416 
Bloodvessels,  changes  in,  of  the  uterus  in  puer- 
peral state,  340 
Blunt  hook,  325 
Body,  delivery  of,  307 
Bowels,  condition  of,  in  puerperal  state,  346 

discharges  from,  of  child,  353 
Breasts,  anatomy  of,  87 

anomalies  of,  91 

care  of,  during  pregnancy,  221 
during  lactation,  349 

changes  in,  during  pregnancy,  182, 187 
during  puerperal  state,  343 

development  of,  91 

disease  of,  in  pregnancy,  444 
in  the  puerperal  state,  343 

enlargement  of,  in  newborn  child,  354 
Breech-presentation  (vide  Pelvic),  276 
Brim  of  pelvis,  25 
Broad  ligaments,  73 
Bromide  of  ethyl,  292 
Brow-presentation,  320 
Bruit  (vide  Souffle),  197 
Bregma,  146 
Bulb  of  ovary,  76 
Bulbs  of  vagina,  56 

Busch's   method   for  performing  cephalic  ver- 
sion, 583 


pACAO  butter  for  nipples,  221,  350 
L    Csesarean  operation,  625 
indications  for,  625 
mode  of  performing,  626 
preparation  of  patient  for,  626 
time  for  doing,  626 
Calcareous  deposits  in  placenta,  449 
Calculi,  vesical,  obstructing  labor,  492 
Cancer  of  uterus  complicating  labor,  489 
Capuron,  cardinal  points  of,  26,  251 
Caput  succedaneum,  248,  354 

changes  in,  after  birth,  354 
in  shoulder-presentation,  286 
secondary,  249 

Cardiac  disease  in  pregnancy,  420 
Care  of  the  breasts  during  pregnancy,  221 
Carunculse  myrtlformes,  49 


Catarrhal  decidual  endometritis,  447 
Catheter,  introduction  of,  49 

use  of,  after  labor,  346 
Caul,  242 

Causes  of  labor,  231,  234 
Cavity  of  body  of  the  uterus,  59 

of  neck  of  uterus,  59 

of  pelvis,  28 

Central  rupture  of  perineum,  545 
Cephalic  version,  581 
Cephalhsematoma,  248,  354 
Cephalotripsy,  636 
Cervix  uteri,  58 

cancer  of,  in  labor,  489 
in  pregnancy,  442 
cavity  of,  59 

changes  in,  in  pregnancy,  178 
in  the  puerperal  state.  341 
portio  yaginalis  of,  53 
lacerations  of,  in  labor,  550 
shortening  of,  in  pregnancy,  178 
softening  of,  in  pregnancy,  178 
tears  of,  in  labor,  550 

Child,  condition  of,  during  second  btage  of  labor, 
301 

artificial  feeding  of,  357 

attention  to.  307,  351 

bathing  of,  355 

breasts  of,  354 

caput  succedaneum,  248, 354 

cephalhsematoma,  248,  354 

care  of,  307, 351 

changes  in  the  shape  of  head,  354 

circulation,  156 

clavicle,  fracture  of,  307 

discharges  from  bladder  and  bowels,  353 

dressing,  310 

dressing  cord,  309 

injuries  to,  by  forceps,  618 

jaundice  of,  354 

milk-secretion  of,  354 

muguet  in,  358 

newborn,  apparent  death  of,  310 

nourishment  of,  355 

skin-desquamation  of,  354 

sleeping  of,  355 

sprue  in,  358 

thrush  in,  358 

umbilical  cord,  353 

hemorrhage  from,  353 

urination,  difficulty  and  pain  in,  358 

washing,  355 

wet-nurse,  selection  of,  356 
Childbed  (vide  Puerperal  state),  333 
Choc,  foetal,  of  Pa  jot,  200 
Chloral  in  eclampsia,  417 

in  labor,  292 
Chloroform  in  eclampsia,  417 

in  labor,  292 

Cholera  in  pregnancy,  429 
Chorea  in  pregnancy,  425 

treatment  of,  426 
Chorion,  127 

Chronic  infectious  diseases  in  pregnancy,  422 
Cicatrices  of  vagina  complicating  labor,  492 

of  os,  486 
Circulation  at  birth,  158 

placental,  156 

vitelline,  156 
Circulatory  apparatus,  changes  in,  in  pregnancy, 

167 
Clefts,  visceral,  139 

palate,  141 
Clitoris,  anatomy  of,  48 

length  of,  48 
Cloaca,  81 

Clothing  during  pregnancy,  218 
Cocaine,  487 
Coccyx,  recession  of,  27 

Cohen's  method  of  treating  placenta  prsevia,  391 
Coiling  of  umbilical  cord,  454 
Coitus  during  pregnancy,  219 
Columnse  rugarum,  54 

Combination  of  male  and  female  elements,  113 
Combined  turning  in  placenta  prsevia,  389 
Complex  presentation  of  foetus  causing  dystocia, 
534 


INDEX. 


681 


Conception,  108 
time  of,  114 

of  year  most  favorable  to,  117 
Conduct  of  labor,  289 
Confinement,  prediction  of  date,  209 
Constipation  in  pregnancy,  227 

in  puerperal  septicaemia,  667 
Contracted  pelvis  indicating  induction  of  pre- 
mature labor,  577 

Contractility  of  uterus  during  pregnancy,  176 
Contraction,  uterine,  force  of,  in  labor,  237 
Contractions,  abdominal,  in  labor,  238 
uterine,  characteristics  of,  in  labor,  236 
nerve-centre  controlling,  70 
Convulsions,  puerperal  (vide  Eclampsia),  406 
Cord,  umbilical  (vide  Umbilical  cord),  134,  353 

anomalies  of,  454 

pathological  conditions  of,  455 
Corpora  albicantia,  96 
Corpus  luteum,  96 

false,  96 

true,  96 

Course  of  twin  pregnancy,  165 
Couveuse,  352 

Coxalgic,  obliquely  contracted  pelvis,  518 
Cramps  in  lower  limbs  in  second  stage  of  labor, 

301 

Cranial  presentation  (vide  Vertex),  252 
Cranioclasm,  635 
Cranioclast,  Braun's,  635 

Simpson's,  635 
Craniotomy,  633 
Cranium,  foetal,  145 

Credo's  method  of  placental  expression,  314 
Crural  hernia  of  uterus  in  pregnancy,  441 

phlegmon  in  puerperal  state,  664 
Cystic  decidual  endometritis,  447 
Cystocele  complicating  labor,  491 


DEATH,  apparent,  in  newborn,  310 
treatment  of,  311 
oi  foetus,  462 

consequences  of,  462 
liquefaction,  463 
maceration ,  464 
mummification,  463 
putrefaction,  464 
diagnosis  of,  462 

sudden,  during  or  following  labor,  672 
from  accidents  of  labor,  675 
from  different  diseases,  675 
from  pulmonary  embolism,  673 
from  syncope,  672 
from  the  entrance  of  air  into  the  uterine 

veins,  674 
Decapitation,  639 
Decidua,  atrophy  of,  448 
formation  of,  119 
reflexa,  119, 172 
serotina,  119 
syphiloma  of,  450 
yera,  119. 172 

Decidual  endometritis,  447 
catarrhal,  447 
cystic,  447 
diffuse,  447 

polypoid,  447  • 

Decollation,  639 

Deficiency  of  uterine  force  in  labor,  478 
Deformities  of  pelvis  caused  by  fractures  or  by 

neoplasms  of  the  pelvic  bones,  520 
Degeneration,  hydatidiform,  of  the  placenta,  451 

myxomatous,  of  placenta,  451 
Delivery,  diagnosis  of  recent,  351 
difficult,  of  shoulders,  306 
of  body,  307 

of  head,  in  head-last  labors,  322 
of  shoulders,  306 
post-mortem,  629 
preparation  for,  302 
Derotomy,  639 

Descent  of  head  in  labor,  260 
Desquamation  of  skin  in  newborn,  354 
Detachment  of  placenta,  causes  of,  382 

complete,  in  treatment  of  placenta  prsevia, 


Detachment,  partial,  in  treatment  of  placenta 

prsevia,  388 

Determining  causes  of  labor,  231 
Development  of  embryo  and  foetus,  138 
of  female  generative  organs,  80 

external  organs  of  generation,  80 
internal  organs  of  generation,  81 
of  mammae,  91 

|  Diagnosis,  differential,  of  pregnancy,  204 
Diameters  of  ftetal  head,  147 
of  maternal  pelvis,  25-28 
Differences  in  pelvis  as  to  individuals,  sex,  age, 

and  race,  33 

I  Diffuse  decidual  endometritis,  447 
I  Digestive  organs,  condition  of,  in  puerperal  state, 
i      336 
Dilatation  of  os  uteri  in  labor,  240 

active  interference  with,  298 
of  vagina,  243 
of  vulva,  243 
sacciform,  of  posterior  wall  of  uterus  during 

pregnancy,  440 
Dilators,  Barnes's,  390 
Directions,  special,  in  labor,  294 
Disease,  malignant,  of  uterus,  in  pregnancy,  442 
of  breasts  during  pregnancy.  444 
of  mother  as  an  indication  for  jnduction  of 

premature  labor,  578 
syphilitic,  of  placenta,  450 
Diseases,    accidental,    occurring    to    puerperal 

women,  645 
acute  infectious,  during  pregnancy,  427 

of  foetus,  460 
chronic  infectious,  during  pregnancy,  422 

of  foetus,  460 
exaggerations  of  physiological  conditions  of 

pregnancy,  395  et  seq. 
infectious,  in  puerperal  state,  642,  647,  651 
intercurrent,  in  pregnancy,  420 
of  heart  during  pregnancy,  420 
of  newborn,  675 

acute  fatty  degeneration,  678 

hsemoglobmuria,  678 
erysipelas,  675 
gonorrhoea,  677 
melsena  neanotorum,  678 
sclerema  neonatorum,  675 
tetanus,  676 
of  umbilicus,  675 
umbilical  hernia,  67  9 
of  ovum,  447 
of  placenta,  449 

of  sexual  organs  in  pregnancy,  433 
of  various  organs  of  foetus  causing  dystocia, 

522 

sporadic,  during  pregnancy,  423 
structural,  of  the  uterus  in  pregnancy,  442 

during  labor,  489 
Disinfection,  190 

Displacement  of  foetal  arm,  dorsal,  causing  dys- 
tocia, 537 
Displacements  of  uterus  during  pregnancy  (viite 

Uterus). 

Double  vagina  and  uterus,  86 
Douglas's  cul-de-sac,  52 
D'Outrepont,  method  of,  performing  cephalic 

version,  583 

Drink  in  first  stage  of  labor,  298 
in  second  stage  of  labor,  302 
Dry  labor,  242 
Duration  of  labor,  247 
of  pregnancy,  209 
Dynamic  pelvis,  23 
Dystocia,  foetal,  530 

from  abdominal  tumors,  487 

from  advanced  ossification  of  the  head  of  the 

foetus,  523 

from  anomalies  of  adjacent  organs,  490 
from  cancer,  489 

from  dorsal  displacement  of  arm,  537 
from  double  monstrosities,  527 
from  great  size  of  foetus,  522 
from  great  size  of  foetus  from  pathological 

causes,  523 
ascites,  527 

diseases  of  various  organs,  527 
encephalocele,  527 


682 


INDEX. 


Dystocia,  from  great  size  of  fretus  from  patho- 
logical cause— hydrocephalus,  527 
hydromeningocele,  527 
hydronephrosis,  527 
hydrothorax,  527 

new  growths  and  foetal  inclusion ,  527 
retention  of  urine,  527 
single  monsters,  527 
from  prolapse  of  members,  535 

or  umbilical  cord,  538 
in  complex  presentations,  534 
in  malpresetHations,  534 
in  plural  deliveries,  530 


UCLAMPSIA,  406 
LJ       attack  of,  407 

Csesarean  operation  in,  418 

diagnosis  of,  414 

essential  cause  of,  412 

etiology  of,  411 

exciting  causes  of,  412 

influence  on  pregnancy  and  labor,  414 

mortality  in,  foetal  and  maternal,  409 

pathological  appearances  in,  411 

predisposing  causes  of,  411 

premonitory  symptoms  of,  407 

prognosis,  410 

treatment,  415 
medical,  415 
obstetrical,  418 
prophylactic,  451 
Embryo,  123 

formation  of,  128 
EmphjMema  in  labor,  477 
EncepHalocele,  527 
Episiotomy,305 
Ergot  in  labor,  314.  483 
Expulsion  of  body  in  labor,  263 
Extension  of  head  in  labor,  262 


FACE,  anomalies  of,  mechanism  in,  275 
auscultation  in,  presentation  of,  271 
causes  of  presentation  of,  269 
descent  of,  in  presentation  of,  272 
delivery  of  body  in  presentation  of,  275 
delivery  of  head  in  presentation  of,  274 
diagnosis  of  presentation,  270 
external  rotation  of  head,  275 
frequency  of  presentation,  269 
internal  rotation  of  body  in  presentation  of, 

275 

management  of,  presentation  of,  319 
mechanism  of  labor  in,  presentation  of,  270 
plastic  changes  in,  presentation  of,  275 
presentation  of,  269 
prognosis  of,  288 
rotation  of,  272 

Fecundated  ovule,  changes  in,  118 
Feeding,  artificial,  357 
Flexion  of  head  in  labor,  258 
Foetal  appendages  in  plural  pregnancy,  164 
Fcetal  head,  145 

diameters,  147  ' 
fontanelles,  146 
movements,  149 
sutures,  146 

Foetal  heart,  sounds  of,  199 
trunk,  diameters  of,  149 
Foetus,  anatomy  of,  138 
anomalies  of,  522,  527 

double  monstrosities,  527 
hydrocephalus,  523 
single  monsters,  527 
size  of,  522 

attitude  of,  in  womb,  150 
development  of.  138,  145 
pathology  of,  459 

amputations  of  members,  461 
fractures  of,  461 

infectious  diseases  occurring  in,  460 
luxations,  461 
rachitis,  461 
tumors,  462,  527 
physiology  of.  138 
positions  of,  431 


Foetus,  positions  of,  left  fronto-anterior,  271 

left  occipito-anterior,  256 

left  occipito-posterior,  266 

left  sacro-anterior,  281 

right  occipito-anterior,  265 

right  occipito-posterior,  266 

right  sacro-posterior,  282 
presentation  of,  151 
Forceps,  application  of,  in  head-first  labor,  r>14 

to  pelvis,  617 

conditions  necessary  for  use  of,  604 
historical,  589 
indications  for  use  of,  604 
in  face-presentation,  615 
in  head-last  labor,  614 
Ostermann's    method    in   occipito-posterior 

position,  614 
powers  of,  596 
preparations  for  using,  606 
varieties,  591 
Funic  souffle,  200 


n  ALACTORRH(EA,  350 
U    Gavage,  352 
Gingivitis,  229 


TT^MORRHOIDS,  227 

U    Hegar's  sign  of  pregnancy,  193 

Hemorrhage,  accidental,  392 

treatment  of,  394 
after  birth  of  child,  560 
secondary,  565 
symptoms  of,  561 
treatment  of,  562 
Heredity,  influence  of,  115 
Hips,  presentation  of,  324 

application  of  blunt  hook  in,  325 

fillet  in,  327 

Pinard's  method  in,  330 
traction  with  fingers  in,  327 
treatment  in,  325,  330 
Hydrsemia  during  pregnancy,  400 
Hymen,  49 
Hyperemesis,  395 
causes  of,  396 
treatment  of,  397,  398 


TNSOMNIA,  229 


JAUNDICE  of  newborn,  354 

V 


T  ABIA  majora,  47 
Jj       minora,  47 
Labor,  anaesthesia  in,  291 
antiseptics  in,  290 
artificial,  231 
conduct  of.  289 
delayed,  231 

determining  causes  of,  231 
diagnosis  of,  252 
discharges  in,  243 
duration  of,  247 
effects  of,  upon  the  child,  246 
effects  of,  upon  the  mother,  247 
efficient  causes  of,  234 
first  stage  of,  298 

condition  of  bladder  and  bowels  in , 

298 

food  and  drink  in,  298 
presence  of  physician  in,  299 
mechanical  phenomena  of,  250,  288 
missed,  216 
pathology  of,  477 

anomalies  of  adjacent  organs,  490 
anomalies  of  force  in,  478 
excess  of  force,  477 
deficiency  of  force,  478 
perversion  of,  483 
of  soft  parts,  485 
of  os  uteri,  485 


INDEX. 


683 


Labor,  pathology  of,  anomalies  of  uterus,  480 
injuries  to  maternal  soft  parts,  543 
inversion  of  uterus,  causes,  568 
diagnosis,  569 
prognosis,  571 
symptoms,  569 
treatment,  571 
rupture  of  uterus,  551 
symptoms  of,  557 

threatened,  555 
treatment,  558 
tears  of  cervix,  550 
of  perineum,  554 
of  vagina,  545 
of  vulva,  544 
thrombus  of  vagina,  548 

of  vulva,  548 
pain  in,  238 
phenomena  of,  236 
physiology  of,  231 
precursors  of,  234 
prediction  of  date  of,  209 
premature,  231 
preparation  of  bed  in,  297 

of  patient  in,  £97 
second  stage  of,  condition  of  child  in,  301 

os  uteri  in,  301 

cramps  in  lower  limbs  in,  301 
drink  in,  302 
food  in,  302 
management  of,  299 

of  twin  labor,  330 
perineum,  care  of,  302 
preparation  for  delivery  in,  302 
special  directions  in,  294 
stages  of,  235 
Lactation,  347 

obstacles  to,  348 

treatment  of,  348 
Levelling,  243,  260 


MAMMAE,  87 
develdpment  of,  91 
"  Maternal  impressions,"  222 

opinions  of  Barker  on,  222 
of  Weissmann  on,  225 
Menstruation,  97 

first  causes  of,,  101 
genital  sense,  102 
heredity,  101 
race,  101 
residence,  101 
theories  of,  103 

Mind,  condition  of,  in  pregnancy,  221 
Mons  veneris,  46 
Morning  sickness,  166 

treatment  of,  225 

Mother,  attention  to,  after  second  stage  of  labor, 
314 


VTAVICULAR  fossa,  50 

II    Nervous  system,  changes  of,  in  pregnancy, 

170 
Neuralgia,  229 

It 

fPDEMA  of  legs,  227 
VJL    Omphalorrhagia,  353 
Operations,  obstetrical,  573 
anaesthesia  in,  573 
antiseptics  in,  573 
Farabeuf  s,  624 
induction  of  abortion,  574 
indications  for,  575 
means  of,  577 
prognosis  in,  577 

induction  of  premature  labor,  577 
indications  for,  577 
means  of,  579 
prognosis  in,  579 
placenta,  removal  of,  620 
symphyseotorny,  621 
version,  581 

bimanual,  583 
cephalic,  581 


Operations,  version,  podalic,  584 
Os  uteri,  dilatation  of,  in  labor,  240 
Osteophytes,  171 
Ovaries,  74 

aspect  of,  76 

bulb  of,  76 

form,  76 

hilum,  76 

nerves,  78 

size,  76 

structure,  77 

vessels,  78 
Oviducts,  79 
Ovisacs,  78 
Ovulation,  92 


PAIN,  after  labor,  334 
character  of,  in  labor,  239 
false,  247 

seat  of,  in  labor,  239 
Palpation,  abdominal,  193 
Parbvarium,  73 
Pelvimetry,  497 
Pelvis,  anatomy  of,  21 
anomalies  of,  493 
ankylotic,  513 

transversely  contracted,  513 
coxalgic,  obliquely  contracted,  518 
deformity  from  neoplasms,  520 
diagnosis  of,  496 
form,  493 

generally  contracted,  flat,  509 
justo-major,  501 
justo-minor,  501 
labor  in,  501 
kyphotic,  516 
Naegele's,  493 
osteomalacic,  511 
position,  493 
simple,  flat,  504 
spondylolisthetic,  509 
axis  of,  29 
cavity  of,  28 
dynamic,  42 
floor  of,  39 
inclined  plane  of,  28 
inlet  of,  25 
joints  of,  21 

changes  in,  172 

inflammation  of,  400 
movements  of,  23 
relaxation  of,  in  pregnancy,  399 
rupture  of,  400 
treatment  of,  399 
uses  of,  24 

horizontal  planes,  29 
obliquity  of,  29 

differences  of,  33 
in  individuals,  33 
in  races,  36 
in  sexes,  34 
presentation  of,  276 

anomalies  of  mechanism  in,  280 

causes  of,  276 

compression  of,  in,  279 

delivery  of  body  in,  280 

descent  in,  279 

diagnosis  of,  277 

external  rotation  of  trunk  in,  280 

internal  rotation  of  head  in,  280 

mechanism  in  different  positions,  281 

of  labor  in,  279 
plastic  changes  in,  281 
positions  of,  281 
rotation  of  anterior  hip  in,  279 
segments  of,  42 
soft  parts  of,  37 
varieties  of,  276 
Perineum,  41 
care  of,  302 

central  rupture  of,  545 
changes  of,  in  pregnancy,  172 
frequency  of  rupture  of,  302 
tears  of,  in  labor,  543 
Phenosalyl,  573 
Placenta,  128 


684 


INDEX. 


Placeuta,   anomalies   of,    circumvallata, 

strata,  marginata.  449 
of  structure,  449 

calcareous  deposits,  449  

my xomatous  degeneration.  450 

fibrous,  450 
detachment  of,  '244 
expulsion  of,  314,  315 
inflammation  of,  white  infarcts,  450 
position  of,  130 
prsevia,  376 

causes  of  detachment  in,  382 
complications  of,  380 
diagnosis  of,  383 
etiology,  378 
frequency  of,  378 
hemorrhage  and  its  source,  381 
prognosis  in,  384 
treatment  of,  384 
Barnes's,  388 
Cohen's  method  in,  391 
combined  method  in,  389 
ergot  in,  388 
Ford's  method,  392 
Murphy's  method,  390 
Puzos'  method,  391 
Simpson's  method,  388 
tampon  in,  385 
varieties  of,  378 
syphilis  of,  450 
tuberculosis  of,  451 
uses  of,  132 
Pregnancy,  151,  255 

breasts,  diseases  of,  in,  444 
cholera  in,  429 
chorea  in,  425 
cystitis  in,  444 
decidua,  atrophy  of,  in,  348 
diabetes  mellitus  in,  444 
diagnosis  of,  184,  201 
differential,  204 
diphtheria  in,  432 
duration  of,  209 
ectopic,  360 

causes  of,  360 
diagnosis  of,  370 
frequency  of,  361 
prognosis  of,  372 
rupture  of,  372 

diagnosis  of,  374 
treatment  of,  374 
treatment,  372 
abdominal  section  in,  374 
electricity  in,  372 
elytrotomy  in,  375 
morphia  in,  372 
varieties,  362 

abdominal,  368 
intra-iigamentous,  370 
interstitial,  375 
ovarian,  367 
tubal,  362 
tubo-ovarian,  367 
endometritis,  decidual  in,  447 
catarrhal  in,  447 
cystic  in,  447 
diffuse,  447 
polypoid,  447 
epilepsy  in,  427 
erysipelas,  431 
.fevers  in,  428 

intermittent,  428 
typhoid,  427 
yellow,  428 

heart,  diseases  of,  in,  420 
hygiene  of,  217 
hysteria  in,  426 
influenza  In,  431 
jaundice  in,  424 
Kidney,  404 
leucorrhcea  in,  434 
management  of,  318 
nephritis  in,  444 
pertussis  in,  432 
phenol  in,  202 
phthisis  in,  422 
pleurisy  in,  424 


fene-    Pregnancy,  pneumonia  in,  423 
prolonged,  211 
rubeola  in,  431 
signs  of,  186 
scarlatina  in,  431 
syphilis,  422 
traumatisms  in,  444 
tumors  in,  ovarian,  443 
uterus  in,  434 

anteflexion  of,  435 
anteversion  of,  435 
hernia  of,  431 
prolapse  of,  434 
prociaentia,  434 
retroflexion,  436 
retroversion,  136 
structural  diseases  of,  442 
vagina,  prolapse  of,  in,  433 
variola,  430 

vulva,  vegetations  of,  in,  433 
Pseudo-cyesis,  206 
Puberty,  92 
Puerperal  fever,  651 

clinical  course,  666 
prognosis,  667 
treatment,  667 
colpitis  in,  658 

endocarditis,  ulcerative,  in,  670 
endometritis  in,  658 

treatment,  659 
entrance  of  poison  in,  656 
influence  of  the  air  in,  657 
mildness  or  severity  of  infection, 

657 

parametritis  in,  660 
perimetritis,  662 
phlegmasia  alba  dolens,  663 
prognosis,  664 
symptoms,  663 
treatment,  664 
prophylaxis,  671 
saprsemia,  665 
severe  forms  of,  665 
pyaemia,  668 
septicaemia,  665 
temperature  in,  657 
time  of  infection,  658 
ulcers  in,  658 
state,  333 

management  of,  333 

attention  to  child  in,  351 

to  mother  in,  343 
care  of  genital  organs  during,  346 
change  in  weight  during,  342 
condition  of  bladder  and  bowels  in,346 

digestive  organs  in,  336 
food  in,  345 
lochia  in,  336 
perspiration  in,  335 
pulse  in,  334 
respiration  in,  335 
rest  during,  344 
retention  of  urine  in,  336 
secretion  of  milk,  324 
temperature  in,  335 
pathology  of,  641 

breasts,  diseases  of  the,  641 
erysipelas,  646 
insanity,  648 
etiology,  649 
prognosis,  649 
treatment,  649 
Insanity  of  lactation,  649 
malarial  fever,  645 
mastitis,  642 

treatment  of,  643 
melancholia,  648 

neuralgia  of  the  lower  limbs  in,  650 
nipple,  diseases  of,  641 
paralysis  of  the  lower  limbs  in,  650 

(  vUICKENING,  187 


RESPIRATION  in  pregnancy,  168 
Rotation  of  head  in  labor,  260 


INDEX. 


685 


Rotation,  external,  of  head  in  labor,  262 
of  body  in  labor,  262 

OALIVATION,  226 

0    Banger's  sign  of  pregnancy,  191 

Scarlatina  in  pregnancy,  431 

in  the  puerperium,  645 
Seminal  fluid,  109 
Sex,  prediction  of,  200,  201 

production,  115 
Sexual  organs,  46,  91 

anomalies  of,  80 
changes  of,  in  labor,  235 
after  labor,  338 
involution  of  uterus,  338 
neck  of  uterus,  341 
position  and  form  of  uterus,  340 
changes  of,  in  pregnancy,  171 
uterus,  172 
vagina,  171 
vulva,  171 
development  of,  80 
Shoulder,  presentation  of,  282 
auscultation  in,  284 
causes  of,  282 
compression  in,  285 
delivery  of  body  in,  285 
delivery  of  head  in,  286 
descent  in,  285 
diagnosis  of,  282 

external  rotation  of  body  in,  286 
internal  rotation  of  head  in,  286 
prognosis  of,  288 
rotation  of  shoulder  in,  285 
spontaneous  delivery  in,  285 
Shoulders,  delivery  of,  306 

difficult  delivery  of,  306 
Skin,  changes  of  the,  in  pregnancy,  169 
Souffle,  uterine.  198 
Spermatozoids,  110 
Striae  gravidarum,  170 
Super-fecundation,  163 
-impregnation,  163 
fcetation,  163 
Synclitism,  260 


^TETANUS  in  the  newborn,  676 
1        in  the  puerperium,  646 


Touch,  rectal,  in  labor,  192,  255 
vaginal,  189 
vesical,  192 


TTMBILICAL  cord,  134 

U    Uterine  ligaments,  72,  73 

Uterus,  57 

bloodvessels  of,  65 

cavity  of  body  of,  59 

cavity  of  neck  of,  60 

lymphatics  of,  68 

mucous  membrane  of,  65 

muscular  coat  of,  61 

nerves  of.  69 

peritoneal  coat  of,  60 

position  of,  60 

structure  of,  60 


\TAGINA,  51 

V        dilatation  of,  in  labor,  243 

Vaginal  bulbs,  56 

Varices,  227 

Vectis,  619 

Vertex  presentation,  252 
auscultation  in,  254 
descent  of  head  in,  260 
diagnosis  of,  252 
expulsion  of  body  in,  263 
extension  of  head  in,  262 
external  rotation  of  head  in,  262 
flexion  of  head  in,  257 
internal  rotation  of  body  in,  262 
mechanism  of  labor  in,  257 
position  in,  255 
prognosis  of,  288 
rotation  of  head  in,  260 

Vestibule,  50 

Vulva,  50 

dilatation  of,  in  labor,  243 
pruritus  of,  227 
general,  227 

Vulval  canal,  50 
glands,  50 


YlfET-NURSE,  selection  of,  356 


Date  Due 


CAT.    NO.    23   233  PRINTED    IN    U.S.A. 


A  000  548  275 


WQ100 
P2T6s 
1895 
Parvin,  Theophilus. 

The  science  and  art  of 

obstetrics 

WQ100 
P2?6s 

1895 
Parvin,  Theophilus. 

The  science  and  art  of  obstetrics 


CALIFORNIA  COLLEGE  OF  MEDICINE  LIBRARY 

UNIVERSITY  OF  CALIFORNIA,  IRVINE 

IRVINE,  CALIFORNIA  92664 


